Policy

Statements

of the

Philippine

Pediatric

Society, Inc.

Committee on Policy Statements Series 2009 Vol. 1 Nos. 1-7

 SERIES 2009 VOL. 1 ISSUE

Obesity in Children and Adolescents 1

Child Labor 7

Infant Walkers 13

Caffeine and Children 17

Medical Certificate for school Entrants 23

Pre-Operative Evaluation in Pediatric Patients 27

Undergoing Surgery and other Major Therapeutic or
Diagnostic Procedures
Sports Clearance 31

ii
 PPS Policy Statements Message
OFFICIAL PUBLICATION OF THE
PHILIPPINE PEDIATRIC SOCIETY,
The Philippine Pediatric Society, Inc., a Specialty Division of the
INC. MD, MAHPS Philippine Medical Association, has its membership composed of
Carmencita D. Padilla,
Editor-in-Chief hardcore advocates of children. Its medical concerns are far beyond
diagnosis and treatment. Child welfare, protection of the
Cynthia Cuayo-Juico, MD environment, caring about the future, growing and enjoying life
Irma R. Makalinao, MD
and living humanely are among the many concerns of Pediatricians.
Co-chairpersons

Jocelyn J. Yambao-Franco, MD
Joel S. Elises, MD
Salvacion R. Gatchalian, MD
Genesis C. Rivera, MD
Advisers
Nerissa M. Dando, MD
Joselyn A. Eusebio, MD
Edilberto B. Garcia, Jr., MD
Ramon C. Severino, MD
Editorial Board
Maria Theresa H. Santos, MD
Gloria Nenita V. Velasco, MD
Research Associates
Philippine Pediatric Society, Inc.
Board of Trustees
OFFICERS
Pediatricians, therefore, are the closest allies of children starting
from conception until they have become adults. The child’s early
life must be remembered as blissful years of youth, though he
struggles through psychological and physical health challenges,
even if he does not feel the direct guidance of his Pediatricians,
must feel and realize later that there was someone else – and it is
that Pediatrician.
The PPS, through its officers and members of the board of Trustees
commends this output of the committee headed by Dr. Carmencita
David Padilla on the series of Policy Statements. Short of being a
legal document, this publication should be adopted as a doctrine of
reference for all child advocates.
Mabuhay ang Filipino.

Victor S. Doctor, MD
President

Genesis C. Rivera, MD Victor S. Doctor, MD

Vice President President
Melinda M. Atienza, MD Philippine Pediatric Society, Inc.
Secretary

Ma. Noemi T. Salazar, MD

Assistant Secretary

Milagros S. Bautista, MD
Treasurer

May B. Montellano, MD
Assistant Treasurer

Jocelyn J. Yambao-Franco, MD
Immediate Past President

Fe V. Del Mundo, MD
Honorary President

MEMBERS
Stephen C. Callang, MD
Joselyn A. Eusebio, MD
Salvacion R. Gatchalian, MD
Alexander O. Tuazon, MD
Florentina U. Ty, MD
Grace Marilou L. Vega, MD
Ma. Victoria C. Villareal, MD

iii
 PREFACE

More than 50% of the population are pediatric in age. The Philippine Pediatric Society remains committed
to protect the Filipino children through its various services by the network of pediatricians throughout the
country. Advocacy remains at the heart of the organization. Child advocacy is worth all the challenges and
difficulties that are experienced, for, in the end, it is ultimately for the benefit of the child. With this fourth
volume of Policy Statements, the Philippine Pediatric Society renews and strengthens its commitment to
the Filipino child.

The PPS policy statements have had a major impact on Philippine Health Policy Development since the
first publication in 2003. A policy statement in the first issue, newborn screening, has been enacted into
Republic Act 9288 or the Newborn Screening Law. The Newborn Screening Law mandates that every
child must be given the opportunity to be offered newborn screening. Today, 2 other policy statements
have been crafted into bills – universal newborn hearing screening (Senate Bill No 2390 sponsored by
Senators Miriam Defensor-Santiago, Pilar Juliana Cayetano, Loren Legarda and Manuel Lapid) and orphan
disorders (Senate Bill No. 3087 sponsored by Senator Edgardo Angara). The Department of Health (DOH)
has included folic acid supplementation among its recommendations to women of reproductive age in its
Maternal-Newborn Health And Policy Strategy Framework. It is envisioned that the PPS policy statements
will serve as basis for health policies that will eventually impact on better health for the Filipino child.

With the assistance and support of the PPS Board of Trustees, committee members, the different
subspecialties, and chapters, the committee presents 9 policy statements.

There are policy statements that have been withdrawn from this volume due to further review and information
from expert reviewers still coming in and due to topics that require further investigation and consultation.

Acknowledgement of the panel of expert reviewers is given at the end of each statement. Some policy
statements were also jointly sponsored.

This issue presents policy statements on:

Obesity in Children and Adolescents, jointly sponsored with the Society of Adolescent Medicine
of the Philippines, Inc;, the Philippine Society of Pediatric Metabolism & Endocrinology. Inc; and
the Philippine Society of Pediatric Gastroenterology and Nutrition;
Child Labor;
Infant Walkers;
Caffeine and Children;
Medical Certificate for School Entrants, jointly sponsored with the Philippine School Health
Officers Association, the Philippine Society of Pediatric Cardiology and Department of
Education;
Pre-Operative Evaluaion in Pediatric Patients Undergoing Surgery and Other Major
Therapeutic or Diagnostic Procedures, jointly sponsored with the Philippine Society for
Pediatric Cardiology; the Child Neurology Society of the Philippines; the Philippine Society for
Pediatric Anesthesia; and the Philippine Society of Pediatric Surgeons;

iv
 Sports Clearance, jointly sponsored with the Philippine Society of Pediatric Cardiology

The issues that the committee were covered in its four publications are just a few of many issues affecting
our children; hence, a lot of areas need to be covered and a lot of work remains. The committee remains
unfazed and ever more ready to accept these challenges as it continues to research and work towards this
goal in the hopes of protecting the future of Filipino children.

The Editors

v
vi
 PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association
In the Service of the Filipino Child

PPS Policy Statements Series 2009 Vol. 1 No. 1

Obesity in Children and the Adolescents

Philippine Pediatric Society, Inc.
Society of Adolescent Medicine of the Philippines, Inc.
Philippine Society of Pediatric Metabolism & Endocrinology, Inc.
Philippine Society of Pediatric Gastroenterology and Nutrition

The problem of obesity has affected not only the affluent Western countries but also the Asian countries
that experienced rapid economic and epidemiological transition in the past 20 years. The effect of this
transition led to increasing prevalence of overweight and obesity among children and adolescents.
The obesity epidemic is said to be caused by the increasing urbanization and the consumption of high-
energy and high-fat foods in populations with reduced levels of physical activity. Obesity in children
and adolescents is related to a lot of diseases and complications and studies have shown that it increases
the risk of serious illnesses and death later in life, thus raising public health concerns. Prevention of
obesity in children and adolescents should be of primary concern. This policy statement presents
information on the prevailing obesity among children and adolescents and cites strategies for the
prevention and early identification of obesity.

KEYWORDS: obesity epidemic, overweight, sedentary lifestyle, body mass index, diabetes, stroke,
cancer, high-fat, high-calorie food
URL: http://www.pps.org.ph/policy_statements/obesity.pdf

BACKGROUND beginning at age 6.10 years. Representative national data are

Being at risk for overweight is defined as a BMI between the
85 th and 95 th percentile for age and gender, and being
overweight is defined as a BMI at or above the 95th percentile
for age and gender. Disadvantages of using BMI include the
inability to distinguish increased fat mass from increase fat-
free mass and reference populations derived largely from non-
Hispanic whites, potentially limiting its applicability to
nonwhite populations.1,2
Weight for length is usually used in the under 2 year age group.
In the United States, being overweight in this age group is
defined as greater than the 95th percentile of the weight for
length. The definition is purely statistical, and the percentile
values are age and gender specific. It is important to measure
head circumference because a very large head may alter
weight-for-length ratio.3
The number of overweight children and adolescents has more
than doubled since the early 1970s. From 1999 to 2000, the
prevalence of overweight (BMI 95th percentile for age and
gender) for children aged 2 to 19 years ranged from 9.9% to
15.5%. The prevalence increased with age and was higher in
racial-ethnic minorities than in non-Hispanic whites. For
example, Mexican American children were significantly more
overweight (23.7%) than non-Hispanic white children (11.8%)
unavailable to estimate reliably the prevalence of overweight
in Asian children and adolescents.4
In the Philippines, the sixth National Nutrition Survey
conducted by the Food and Nutrition Research Institute in
2003 showed that among the 4,110 children aged 0-5 surveyed,
1.4% were overweight (only 0.4% in 1998). Among children
between ages 6-10, 1.3% were overweight (negligible
percentage in 1998); and among 11-19-year-olds, 3.5% were
overweight. These data showed that the number of overweight
children increased between the years 1998 and 2003.5 These
figures were based on the old system of classification using
weight for age, not BMI.
The Department of Education, through the Health and
Nutrition Center (HNC), conducts nutritional assessment of
public school students twice within each school year. The
nutritional assessment of elementary students based on weight-
for-height and body mass index (BMI) conducted towards
the end of school year 2003-2004 showed that out of
10,383,276 children assessed, 1,870,404 or 18.01% were
below normal; 8,188,319 or 78.86% were normal; and 324,553
or 3.13% were above normal. Nutritional assessment of
secondary school students based on body mass index
conducted in March 2004 showed that out of 3,145,011
students weighed, 12.59% were below normal, 84.50% were
normal, and 2.91% were above normal.6
1
PPS Policy Statement
In 2001, a local study was done among schoolchildren aged 8
to 10 years from private and public schools in Manila which
showed that undernutrition was much more prevalent among
public schoolchildren while overnutrition was much more
prevalent among private schoolchildren.7 The increasing
prevalence of overweight among private school children was
also seen in a study done by Chan-Cua. The study included
1822 boys from Grade I-VII of a private school in Metro Manila.
Weight:Height ratio (WHR) was used to assess overweight and
obesity in the students. Based on the Philippine (FNRI-PPS)
growth reference chart, 17% of the boys were overweight and
47% were obese. Based on the National Center for Health
Statistics (NCHS) growth reference chart, 16% were assessed
to be overweight and 41% obese. Obesity was also assessed
based on BMI. A striking 47% had BMI of >20. Majority of the
boys assessed came from the middle and upper socioeconomic
classes with Chinese ancestry, which could be considered a
“high risk” population.8
Genes are important in determining a person’s susceptibility
to weight gain, but energy balance is determined by calorie
intake and physical activity. Some forces thought to underlie
this epidemic are economic growth, modernization,
urbanization and globalization of food markets.3
Pathologic obesity is associated with endocrine or neurologic
disorders or is due to iatrogenic causes, e.g. medications.3
Obesity, at first glance, may seem to be a problem of the
individual himself, but we must also recognize that it as a
problem rooted in neighborhoods and schools, modes of
transportation, local food availability, food advertising to
children and governmental policies.9
Food intake and activity in young children are strongly influenced
by parents. During early childhood, the more parents encourage
children to eat certain foods, the less likely they are to do so. Thus,
foods that have been forbidden in childhood may be overconsumed
when children finally have access to them later on.10 Social support
from parents, siblings and other members of the community
correlates strongly with involvement in physical activity. It is,
therefore, not surprising that children who suffer from neglect,
depression, or other related problems are at significantly increased
risk for obesity during childhood and later in life.11
The rise in consumption of fast food may be relevant to the
childhood obesity epidemic. Fast food incorporates all of the
potentially adverse dietary factors, such as saturated and trans
fat, high glycemic index, high energy density, and large portion
size. A large fast food meal (double cheeseburger, French fries,
soft drink, dessert) could contain 2200 kcal, which, at 85 kcal
per mile, would require a full marathon to burn off.11 Family
life has changed a lot over the past years, with trends towards
eating out and greater access to television than before. It is
2 syndrome, after 10 years of age. Determination of serum or
Obesity in Children and the Adolescents
said that children consume more energy when meals are eaten
in restaurants than at home, possibly because restaurants tend
to serve larger portions of energy dense foods.11
Today’s youth are considered the most inactive generation in
history. This is caused in part by reductions in school physical
education programs and unavailable or unsafe community
recreational facilities. 12 According to the World Health
Organization, nearly two-thirds of children in both developed
and developing countries are insufficiently active, with serious
implications on their future health.13
In the 1998 Asian Conference on Early and Childhood
Nutrition, the Food and Nutrition Research Institute reported
that the most common leisure activities of Filipino children
aged 8 to 10 were playing computer games, reading, and
watching television.14 Another survey of children aged 8 to
10 years in Manila conducted by FNRI showed that only one
out of four children participated in actual physical exercise
everyday. Three out of four spent their time playing computer
games, watching television, and reading. It was also reported
that children had physical education lessons only once or twice
a week.15
Television viewing is thought to promote weight gain by
increasing energy intake and displacing physical activity.
Children seem to passively consume excessive amounts of
energy-dense foods while watching television. Television
advertising could adversely affect dietary patterns at other
times throughout the day and exposure to commercials
increases the likelihood that children later select an advertised
food when presented with options.11
Being severely overweight in childhood is associated with
relatively rare immediate morbidity from conditions, such as
pseudotumor cerebri, slipped capital femoral epiphysis,
steatohepatitis, cholelithiasis, and sleep apnea. Being overweight
is also associated with a higher prevalence of intermediate
metabolic consequences, such as insulin resistance, elevated blood
lipids, increased blood pressure, and impaired glucose tolerance.
These conditions, which are often asymptomatic, increase the
long-term risk for developing diabetes and heart disease in
adulthood and are associated with persistent obesity into
adulthood. However, the recent emergence of medical conditions
that are “new” to overweight children, such as type 2 diabetes,
represents the increasing prevalence of more serious, shorter term
morbidity. Perhaps the most significant morbidities for overweight
children and adolescents are psychosocial.3,5
Laboratory investigations directed at identifying co-morbidities
of obesity may include thyroid functions, lipid profile, complete
chemistries and hepatic profile, and fasting glucose and insulin.
An oral glucose tolerance test (OGTT) should be considered to
exclude impaired glucose tolerance or T2DM in individuals at
high risk, e.g. family history of T2DM and/or metabolic
urinary cortisol
Obesity in Children and the Adolescents
levels should be reserved to exclude the presence of Cushing’s
syndrome in obese individuals who have appropriate historical
information and/or physical findings.
Infants who are hypoglycemic or require very frequent
feedings as well as infants with dysmorphic features require
further evaluation. Examples include persistent
hyperinsulinemic hypoglycemia of infancy (OMIM no. 61820)
and BWS with hypoglycemia, or PWS and BBS with
dysmorphism.3
Recommendations
1. The PPS recognizes that the battle against childhood
obesity in the Philippines is both difficult and laborious.
Thus, in addition to the abovementioned policies, it is
the position of the PPS to adopt the following (additional)
preventive measures:
i. Breastfeeding seems to lower the risk of future obesity.
A review of current literature support a strong
relationship between exclusivity and duration of
breastfeeding to reduction of childhood obesity. These
evidences showed the advantages of breastfeeding,
especially if exclusive, and noted that the favorable
effects are more prominent in adolescence. Plausible
mechanisms why breastfeeding lowers obesity risk
include learned self-regulation of energy intake,
metabolic programming in early life and inherent
properties of breast milk.20,21 Metabolic programming
will lead to higher plasma insulin in bottle/formula
fed infants resulting to stimulation in fat deposition
and early development of adipocytes. Breast milk, on
the other hand, contains bioactive factors which
modulate epidermal growth and tumor necrosis factors
that inhibit adipocyte differentiation.
ii. Nutrition
a. Home-cooked meals should be encouraged as
opposed to eating out in restaurants.
b. Avoidance of fast food
iii. Physical activity
a. Engage in regular exercise.
b. Minimize viewing of television.
c. Encourage family support.
2. To solve the problem of obesity, however, a cooperative
effort among various individuals and groups of people
from all segments of society is of prime importance. Each
one has a role in preventing childhood obesity and
ensuring that our children become healthy, well-nourished
adults.
Roles of Government and Community Leaders
PPS Policy Statement
1. Community leaders should make safe community
facilities available for children’s physical activities.
2. The government, through its agencies, should intensify
information campaigns on proper nutrition and healthy
lifestyle.
3. The government should regulate marketing and promotion
of food products to children.
4. The government, through the Department of Education, should
monitor the strict implementation of the DECS Memorandum
No. 373 s. 1996: “Encouraging the Sale and Consumption of
Healthy and Nutritious Foods in the Schools.”
5. The government should support researches on overweight
and obesity of Filipino children and adolescents.
6. The government should give due recognition to food
manufacturers and establishments that promote healthy
foods.
7. The government, through the Department of Health, should
push for the approval of the pending Administrative Order
regarding the mandatory labeling of nutrition facts and
health claims on pre-packaged food.
8. The government should retrain health workers on the use
of the Center for Disease Control percentile charts for
classification of overweight and obese.
Roles of Marketing, Media and Advertising Industry
1. The media and advertising industry should intensify
information dissemination on the prevention and control
of childhood obesity and its harmful consequences.
2. The Ad Board should strengthen its commitment to
safeguard truth in food advertising.
3. The Ad Board should invite physicians from concerned
medical societies to serve as members of their technical
committee that screens advertisements.
Roles of School Administrators and Teachers
1. School administrators and teachers should ensure the
implementation of physical education in their curriculum.
2. School administrators should provide safe facilities to
encourage children to be more active: bigger playgrounds,
basketball courts, and the like.
3. School administrators and teachers should ensure that
school cafeterias provide healthy food and beverages.
4. School administrators and teachers should work together
with the school health personnel in monitoring the
nutritional status of all pupils and students.
Roles of Parents and Primary Caregivers
1. Parents should be role models for their children. Parents
should be mindful of their eating habits and physical
activities.
2. Parents should introduce at around 6 months of age a
variety of foods, including vegetables and fruits in the diet.
3. Parent should provide healthy food options (adequate
calories but low in saturated fat, low salt, low simple
sugar). Meals consisting of nutritious foods prepared at
home should be encouraged instead of consuming fast3
food meals.
PPS Policy Statement Obesity in Children and the Adolescents

4. Parents should encourage and provide opportunities for *Lead Reviewer

more physical and sports activities and reduce sedentary PANEL OF EXPERT REVIEWERS
activities (watching television, playing computer or
video games). Society of Adolescent Medicine of the Philippines, Inc.
5. Parents should give their children home prepared Rosa Ma. Nancho, MD
nutritious foods as school snacks and meals. Erlinda Cuisia-Cruz, MD
6. Parents should discourage their children from buying Alicia Berbano-Tamesis, MD
unhealthy food (soft drinks, candies, chips) in school
cafeterias. Philippine Society of Pediatric Metabolism and
7. Parents should refrain from using food as reward for Endocrinology, Inc.
their children. Physical activity and quality time with Sioksoan Chan-Cua, MD
parents should reward desired behavior instead. Susana Campos, MD
8. Parents should read nutrition information on food
labels. Nutrition Foundation of the Philippines
Rodolfo Florentino, MD, PhD
Roles of Physicians
1. Physicians should obtain a thorough dietary, Philippine Society of Pediatric Gastroenterology and
psychosocial and family history on the pediatric patient. Nutrition
Hypertension, dyslipidemias, tobacco use, and other Randy P. Urtula, MD
conditions that can be cardiovascular risk factors should Juliet Sio-Aguilar, MD
be identified and addressed. Mary Jean Guno, MD
2. Physicians should monitor height, weight, and BMI Grace Battad, MD
of children and adolescents at every clinic visit. They Paciencia Macalino, MD
should identify those at risk for overweight and Aurora Genuino, MD
obesity. Rebecca Castro, MD
3. Physicians should advocate exclusive breastfeeding for
at least 6 months and onwards; and proper PPS Committee on Nutrition and Promotion of Breastfeeding
complementary feeding. Mary Jean Guno, MD
4. Physicians should educate the family on healthy eating Randy Urtula, MD
and regular exercise habits early in the child’s
development. Useful information may be made PPS Obesity Working Group
available through brochures or waiting room posters. Grace Uy, MD
5. Physicians should refer to registered nutritionist - Susan Jimenez, MD
dietitians for proper dietary management. Grace Battad, MD
6. Physicians should refrain from using food as “rewards.” Sioksoan Chan-Cua, MD
Gemma Dimaano, RD

Document prepared by Committee on Policy Statements:

Chairperson: Carmencita D. Padilla, MD, MAHPS
Co-chairpersons: Cynthia Cuayo-Juico, MD and Irma R.
Makalinao, MD
Members: Nerissa M. Dando, MD; Joselyn A. Eusebio,
MD*; Edilberto B. Garcia, Jr., MD; Ramon C. Severino,
MD
Advisers: Joel S. Elises, MD; Genesis C. Rivera, MD;
Jocelyn J. Yambao-Franco, MD
Council on Community Service and Child Advocacy
Directors: Salvacion Gatchalian, MD; Roberto Espos, Jr.,
MD; Gregorio Cardona, Jr., MD
Research Associates: Lady Christine Ong Sio, MD; Maria
Corazon Martin, MD; Tiffany Tanganco, MD; Aizel de la
Paz, MD; Domiline Coniconde, MD; Emmanuel Arca, MD;
Gloria Nenita Velasco, MD; Maria Theresa Santos, MD
4
ACKNOWLEDGEMENTS
Participants of the Round Table Discussion on Obesity in
Children and Adolescents (01 October 2004):
Ma. Theresa Bacud – Health Education Promotion Officer
III, Health and Nutrition Center, Department of Education
Jane Mari Cabulisan, MD – Medical Specialist II, National
Center for Disease Prevention and Control, Department of
Health
Frances Prescilla Cuevas – Chief, Health Program Officer,
National Center for Disease Prevention and Control,
Department of Health
Sioksoan Chan-Cua, MD – Director, Philippine Association
for the Study of Overweight and Obesity; President,
Philippine Society of Pediatric Metabolism and
Endocrinology, Inc.
Obesity in Children and the Adolescents
Cristina Dablo, MD – Division Chief, Medical Officer VII,
Healthy Lifestyle Division, National Center for Disease
Prevention and Control, Department of Health
Aurora Gamponia, MD – Secretary, Philippine Society of
Pediatric Cardiology
Ma. Rhodora Garcia-De Leon, MD – President, Philippine
Society of Pediatric Cardiology
Merlita Nolido – Chief Education Program Specialist,
Bureau of Elementary Education, Department of Education
Antonia Siy – Senior Counselor, Center for Family
Ministries Foundation
Florentino Solon, MD – President and Executive Director,
Nutrition Center of Philippines
Alicia Berbano-Tamesis, MD – Founding President, Society
of Adolescent Medicine of the Philippines, Inc.
Maria Lourdes Vega – Chief, Nutrition Information and
Education Division, National Nutrition Council
Virgie Velasco – Performance Officer, Kapisanan ng mga
Brodkaster ng Pilipinas
Estrella Paje-Villar, MD – President, Philippine Pediatric
Society
Salvacion Gatchalian, MD – Director, Council on Community
Service and Child Advocacy, Philippine Pediatric Society, Inc.
Carmencita David-Padilla, MD – Chairperson, Committee
on Policy Statements, Philippine Pediatric Society, Inc.
Cynthia Cuayo-Juico, MD – Co-chairperson, Committee on
Policy Statements, Philippine Pediatric Society, Inc.
Nerissa Dando, MD – Member, Committee on Policy
Statements, Philippine Pediatric Society, Inc.
Joselyn Eusebio, MD – Member, Committee on Policy
Statements, Philippine Pediatric Society, Inc.
Edilberto Garcia Jr., MD – Member, Committee on Policy
Statements, Philippine Pediatric Society, Inc.
Irma Makalinao, MD – Member, Committee on Policy
Statements, Philippine Pediatric Society, Inc.
Ramon Severino, MD – Member, Committee on Policy
Statements, Philippine Pediatric Society, Inc.
Aizel de la Paz, MD – Research Associate, Committee on
Policy Statements, Philippine Pediatric Society, Inc.
Tiffany Tanganco, MD – Research Associate, Committee
on Policy Statements, Philippine Pediatric Society, Inc.
Participants of the Round Table Discussion on Obesity in
Children and Adolescents (11 October 2005):
Lorna Abad, MD – Member, Philippine Society of Pediatric
Metabolism & Endocrinology, Inc.
Sofia Amarra, PhD - Senior Science Research Specialist,
Food and Nutrition Research Institute
Nerissa Babaran - Nutrition Officer IV, National Nutrition
Council
Jane Mari Cabulisan, MD – Medical Specialist II, National
Center for Disease Prevention and Control, Department of
Health
PPS Policy Statement
Sioksoan Chan-Cua, MD – Director, Philippine Association
for the Study of Overweight and Obesity; President,
Philippine Society of Pediatric Metabolism and
Endocrinology, Inc.
Sylvia Estrada, MD – Member, Philippine Society of
Pediatric Metabolism & Endocrinology, Inc.
Ma. Rhodora Garcia-De Leon, MD – President, Philippine
Society of Pediatric Cardiology
Rosa Maria Nancho, MD – President, Society of Adolescent
Medicine of the Philippines, Inc.
Thelma Navarrez, MD - Director II, Health and Nutrition
Division, Department of Education
Juliet Sio-Aguilar – Member, Philippine Society of Pediatric
Gastroenterology and Nutrition, Inc.
Edison Ty, MD - Board Member, Philippine Society of
Pediatric Cardiology
Randy Urtula, MD – President, Philippine Society of
Pediatric Gastroenterology and Nutrition, Inc.
Grace Uy, MD - Chair, Obesity Working Group, Philippine
Pediatric Society, Inc. Committee
Felicidad Velandria - Treasurer - Philippine Association of
Nutrition, Inc.
Estrella Paje-Villar, MD – President, Philippine Pediatric
Society
Jocelyn Yambao-Franco, MD – Vice-President, Philippine
Pediatric Society
Carmencita David-Padilla, MD – Chairperson, Committee
on Policy Statements, Philippine Pediatric Society, Inc.
Nerissa Dando, MD – Member, Committee on Policy
Statements, Philippine Pediatric Society, Inc.
Emmanuel Arca, MD – Research Associate, Committee on
Policy Statements, Philippine Pediatric Society, Inc.
Domiline Coniconde, MD – Research Associate, Committee
on Policy Statements, Philippine Pediatric Society, Inc.
The Committee on Policy Statements recognizes the
contribution of the following:
Center for Family Ministries Foundation
Department of Education – Bureau of Elementary Education
Department of Education – Health and Nutrition Center
Department of Health – National Center for Disease
Prevention and Control
Department of Science and Technology - Food and Nutrition
Research Institute
Kapisanan ng mga Brodkaster ng Pilipinas
National Nutrition Council – Nutrition Information and
Education Division
Nutrition Center of Philippines
Philippine Association for the Study of Overweight and
Obesity
Philippine Association of Nutrition, Inc.
Philippine Society of Pediatric Cardiology
5
PPS Policy Statement Obesity in Children and the Adolescents

Philippine Society of Pediatric Metabolism and
Endocrinology, Inc.
Society of Adolescent Medicine of the Philippines, Inc.
REFERENCES
1. Kuczmarski RJ, Ogden CL, Guo SS et al. 2000 CDC
Growth Charts for the United States: methods and
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Control and Prevention; 2003. Available at
www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm.
Accessed September 24, 2006.
3. Obesity Consensus Working Group. The Journal of
Clinical Endocrinology & Metabolism. Mar 2005;
90(3): 1871-1887.
4. Ogden CL, Carroll MD, Flegal KM. Epidemiologic
trends in overweight and obesity. Endocrinol Metab
Clin North Am. 2003; 32: 741-760.
5. Screening and Interventions for Overweight in Children
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6. Lobstein T, Baur L, Uauy R. Obesity in children and
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7. Must A, Strauss RS. Risks and consequences of
childhood and adolescent obesity. Int J Obes Relat
Metab Disord. 1999;23(suppl 2):S2-S11.
8. Zametkin AJ, Zoon CK, Klein HW, Munson S.
Psychiatric aspects of child and adolescent obesity: a
review of the past 10 years. J Am Acad Child Adolesc
Psychiatry. 2004; 43; 134-150.
9. Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH.
Prevalence of a metabolic syndrome phenotype in
adolescents: findings from the third National Health and
Nutrition Examination Survey, 1988-1994. Arch Pediatr
Adolesc Med. 2003; 157: 821-827.
10. The 6th National Nutrition Surveys: Initial Results. Food
and Nutrition Research Institute. Available at http://
www.fnri.dost.gov.ph/nns/6thnns.pdf. Accessed on
October 6, 2004.
11. Department of Education – Health and Nutrition Center.
Integrated School Health and Nutrition Program Q &
A (Questions and Answers). September 2004. Available
at the Department of Education.
12. Florentino R. A study of overweight and obesity among
school children in Manila. Paper read at the 2nd Asia-
Oceania Conference on Obesity (MASO 2003),
Renaissance Hotel, Kuala Lumpur, Malaysia,
September 8, 2003.
13. Chan-Cua S, Cuayo-Juico C, et al. Prevalence of
overweight among boys in a Metro Manila private grade
school. Journal of ASEAN Federation of Endocrine
Societies. 1995:16-20.
14. Galvez MP, Frieden TR, Landrigan PJ. Obesity in the
21 st century. Environmental Health Perspectives.
2003;111(13):A684-5.
15. Dietz WH. The obesity epidemic in young children.
Br Med J 2001;322:313-4.
16. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood
obesity: public-health crisis, common sense cure. The
Lancet 360:473-82.
17. American Obesity Association Fact Sheets. Available at
h t t p : / / w w w. o b e s i t y. o r g / s u b s / f a s t f a c t s /
obesity_youth.shtml. Accessed on August 30, 2004.
18. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood
obesity: public-health crisis, common sense cure. The
Lancet 360:473-82.
19. Why childhood obesity levels are rising. Available at
http://www.tinajuanfitness.info/articles/art120799.html.
Accessed on December 5, 2003.
20. More Filipino kids becoming obese. Available at http:/
/www.inq7.net.lif/2003/nov/13/lif_32-1.htm. Accessed
on April 23, 2004.

DISCLAIMER:
The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision
of quality health care to children. The recommendations contained in this publication do not dictate an exclusive
course of procedures to be followed but may be used as a springboard for the creation of additional policies.
Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and
advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences
in the specific approach. All information is based on the current state of knowledge. Changes may be made in this
publication at any time.

6
 PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association
In the Service of the Filipino Child

PPS Policy Statements Series 2009 Vol. 1 No. 2

Child Labor
Philippine Pediatric Society, Inc.

Child labor is very prevalent specially in developing countries like the Philippines. This puts
the children at risk for abuse and exploitation, exposes them to hazardous environments and
also compromises their health. This policy statement discusses the impact of child labor in
children, the various laws that have been enacted to quell this problem and recommendations
for parents, physicians and the government on how to protect our children from child labor
and uphold the rights of a child.

Keywords: child labor, child abuse, exploitation, children’s right

URL: http://www.pps.org.ph/policy_statements/child_labor.pdf

BACKGROUND A National Statistics Office’s Survey on Children in 2001

The Convention on the Rights of the Child outlines the rights
of every child. Children have the right to life, an adequate
standard of living, parental care and support, social security,
a name, nationality, and identity, information, leisure,
recreation, and cultural activities, opinion, freedom of thought,
conscience, religion, freedom of association, and privacy. In
spite of this, childrens’ rights continue to be violated in the
form of child labor.1
An estimated 246 million children around the world engage
in child labor, of which roughly three-quarters work in
hazardous situations or conditions, such as mines, working
with chemicals and pesticides in the agricultural sector, or
working with dangerous machinery. They are found in homes
as domestic servants, behind walls of workshops as laborers,
and in plantations. At least 70 percent work in agriculture.
Girls, in particular, are especially vulnerable to exploitation
and abuse, working as domestic servants or unpaid household
help under horrific circumstances. They are either trafficked
(1.2 million), forced into debt bondage or other forms of
slavery (5.7 million), prostitution and pornography (1.8
million), participating in armed conflict (0.3 million), or other
illicit activities (0.6 million). The Asian and Pacific regions
have 127.3 million child laborers, representing 19 percent of
children, the largest in the 5 to 14 age group.2
recorded a total of 24.9 million Filipino children, of which 4.0
million were economically active, i.e., one out of six (6) children
worked. Most working children came from Southern Tagalog,
followed by Central Visayas and Eastern Visayas. They were
composed of children aged 10-14 years old and 15-17 years
old, consisting of more males than females, and majority (7 out
of 10) resided in rural areas. More than 50 percent were engaged
in agriculture, hunting, and forestry, while others were in
wholesale and retail, repair of motor vehicles and personal and
household goods, in private households with employed persons,
fishing, and manufacturing. Most were unpaid workers in their
own household-operated farm or business, while one-fifth were
found in private establishments and in private households. Three
out of 5 children were not paid. Roughly 25 percent of working
children aged 5 to 17 years worked in the evening.3
Sixty percent of the working children, or about 2.4 million,
were exposed to hazardous environment. Physical
environment hazards were the most common, of which 44.4
percent were exposed. Around 237,000 (9.9%) were exposed
to physical, chemical, and biologically hazardous
environments. Physical hazards included temperature or
humidity (most common), slip/trip fall hazards, noise,
radiation/ultraviolet/microwave, pressure. Children in
agriculture, hunting, and forestry were greatly exposed to
physical hazards. One out of 5 children was exposed to
chemical elements (such as silica and saw dust and
7
PPS Policy Statement
mist/fumes). Almost 1 in 5 working children was in danger of
biological infections, fungal and bacterial being the most
common. Unfortunately, of the more than 2.4 million working
children who used tools/ equipment in their work, only about
683,000 (35.3%) were provided with safety/protective device/
equipment. Approximately 23 percent of working children
incurred injuries while at work, such as cuts, wounds and/or
punctures, contusions/bruises/hematoma, and abrasions.2
Although 7 in every 10 working children attended school, 1.2
million (44.8%) encountered problems, including difficulty
in catching up with the lesson, high cost of school supplies/
books/transportation, far distance of the school from their
residence, unsupportive teachers, and lack of time for studying.
Not surprisingly, 2 in every 5 working children stopped or
dropped out of school. Reasons for dropping out included
loss of interest and high cost of schooling.2
Because of the conditions that child laborers are forced to
work in, which are intensive and unhygienic, these children
tend to be underweight and undernourished. They are also
exposed to a variety of chemical, biological, and physical
hazards.6 Possible long-term repercussions of child labor
include inhibited development of a country’s human resources,
reduction of lifetime earnings of individuals, and lowered
levels of productivity.6
The ILO Convention No. (ILOC) 138 sets minimum ages
above which work can be allowed as necessary or even a
useful part of young people’s lives.7,8 ILO Convention No.
182 identifies the different worst forms of child labor. It also
sets policies for the elimination of child labor - the worst forms
to be eliminated immediately while other forms should be
restricted in time by establishing minimum age laws and other
legal frameworks that protect children from exploitation.9,10
Republic Act (RA) 9231, more popularly known as the “Anti-
Child Labor Law,” amended some provisions of RA 7610. The
Act provides for the elimination of the worst forms of child labor
and affords stronger protection for the working child. It has the
following salient features: 1. it prohibits the engagement of a
child in worst forms of child labor; 2. provides for the working
hours of a working child aged below 15 and those aged 15 but
below 18; 3. determines ownership, usage and administration of
the working child’s income; 4. provides for the setting up of a
trust fund to preserve part of the working child’s income; 5.
provides stiffer penalties against acts of child labor, particularly
its worst forms, penalizes parents and legal guardians who violate
the provisions of the Act with a fine or community service; and
6. provides for the speedy prosecution of child labor cases.
The worst forms of child labor are the following:
1) All forms of Slavery as defined under the “Anti-trafficking
in Persons Act of 2003”, or practices similar to slavery
8
Child Labor
like sale and trafficking of children, debt bondage, forced
labor, recruitment of children in armed conflict.
2) Child for prostitution, pornography
3) Child for illegal activities/illicit activities
4) Work which is hazardous or harmful to the health, safety
or morals of children, such that it:
a) Debases, degrades, or demeans the intrinsic worth
or dignity of the child
b) Exposes child to abuses
c) Is performed underground, underwater or dangerous
heights
d) Involves use of dangerous machineries, equipment
or tools
e) Exposes child to physical danger like dangerous feats
of balancing, physical strength, or manual transport
of heavy loads
f) Is performed in an unhealthy environment exposing
the child to hazardous working conditions, elements
or substances, co-agents, or processes
g) Is performed under particularly difficult conditions
h) Exposes child to biological agents, such as bacteria,
fungi, viruses, etc.
i) Involves the manufacture of explosives and
pyrotechnic products
In the Philippines, minimum employable age is set at 15 years
old. Children between 15 and 18 years old may be employed in
undertakings not hazardous or deleterious in nature, i.e. any
kind of work in which the employee is not exposed to any risk
that constitutes an imminent danger to his or her life and limb,
safety, and health. A child below 15 years old is not permitted
to work in any public or private establishment, with two
exceptions: children working directly under the sole
responsibility of his or her parents or guardians or legal guardian
(where only members of the employer’s family are employed)
and if the child can go to school and her or his life, safety,
health, morals and development are not endangered; and where
the child’s employment or participation in public entertainment
or information through cinema, theater, radio or television is
essential. These are subject to conditions and provisions as
determined by the Department of Labor and Employment
(DOLE).1 Children of any age, however, are strictly prohibited
from performing for advertisements that promote alcoholic
beverages, tobacco, and violence.5
Still, children below 15 are not allowed to work more than 4
hours per day, 5 days per week. Children between 15 and 18
are allowed to work in non-hazardous circumstances, for not
more than 8 hours per day and not more than 40 hours per
week. In addition, working children are to have, at any time,
access to primary and secondary education and training
(formal or non-formal).10,11
The wages, salaries, earnings, and other income of the working
child shall belong to him/her in ownership and shall be set
Child Labor
aside primarily for his/her support, education or skills
acquisition and secondarily to the collective needs of the
family. Not more than twenty percent (20%) of the child’s
income may be used for the collective needs of the family.
A trust fund must be established to preserve part of the working
child’s income. The parent or legal guardian of a working
child below 18 years of age shall set up a trust fund for at
least thirty percent (30%) of the earnings of the child whose
wages and salaries from work and other income amount to at
least two hundred pesos (P200,000.00) annually, for which
he/she shall render a semi-annual accounting of the fund to
the Department of Labor and Employment. The child shall
have full control over the trust fund upon reaching the age of
majority.
In addition, the Act provides for maximal penalties for
violators (e.g. employers, subcontractors or others facilitating
the employment of children in any of the worst forms of child
labor) and sets penalties for involving children in hazardous
work. It also allows children, parents, or other concerned
citizens to file complaints. RA 9231 “holds parents liable in
case of violation of the said Act and provides penalties for
them such as payment of a fine of not less than Ten Thousand
Pesos (P10,000) but not more than One Hundred Thousand
Pesos (P100,000), or be required to render community service
for not less than thirty (30) days but not more than one (1)
year, or both such fine and community services at the discretion
of the court. The maximum length of community service shall
be imposed on parents who have violated the provisions of
this Act three (3) times.”11
Child labor refers to any work performed by a child that:
1. Subjects the child to economic exploitation, or
2. Is likely to be hazardous for the child, or
3. Interferes with the child’s education, or
4. Is harmful to the child’s health or physical, mental,
spiritual, moral, or social development.
It is a situation wherein children are compelled to work on a
regular basis. In addition, it refers to work where children are
separated from their families and where children are forced
to lead prematurely adult lives.4 As opposed to child labor,
child work children’s or adolescent’s participation in economic
activity that does not negatively affect their health and
development or interfere with their education and, in this light,
can be positive and is legal.2
The Philippines has ratified ILOCs 138 and 182. It has
developed and implemented a national program for the
elimination of the worst forms of child labor. The Philippine
Time-Bound Program Against Child Labor, launched in 2002,
emphasizes combining sectoral, thematic, and area-based
approaches in combating child labor. In support of the
PPS Policy Statement
program, the ILO-International Programme on the Elimination
of Child Labor (IPEC) has implemented a project that involves
strengthening the enabling environment for the elimination
of the worst forms of child labor and direct action for child
laborers, their families, and communities.7
The Philippine Program Against Child Labor is the flagship
program for combating the worst forms of child labor in the
country 5 and involves several agencies (such as the
Department of Labor and Employment, Department of Justice,
Department of Social Welfare and Development (DSWD),
Department of Health), the police, and non-government
organizations. The Bureau of Working Conditions is
responsible for conducting labor inspections and for
monitoring the use of child labor.11 The Department of Labor
and Employment is the lead agency in the implementation of
the Philippine Program Against Child Labor (formerly
National Program Against Child Labor). Other program
partners include the employers group, such as the Employers
Confederation of the Philippines and workers organizations,
such as the Federation of Free Workers and the Trade Union
Congress of the Philippines.
The multi-agency program Sagip Batang Manggagawa allows
for the rescue of child laborers and the placement of these
children in DSWD-managed centers or institutions where they
undergo rehabilitation prior to reintegration. The agency’s
Conditional Cash Transfer provides money to families in need
on the condition that human capital investments be made, e.g.
sending their children to school and bringing them regularly
to health centers. Receipt of money is contingent on enrollment
and regular attendance of at least 85 percent of school days.12
The Philippine Pediatric Society, Inc. is in support of the
elimination of the worst forms of child labor and of protecting
children in the employable age.
RECOMMENDATIONS
Roles of the National Government
1. The national government should continue to enhance
existing legislation that will help in the elimination of
the worst forms of child labor in the country.
2. The national government should ensure child-friendly and
child-sensitive enforcement of existing anti-child labor
legislation.
3. The national government should include child labor
concerns in the following areas:
a. National Development
b. Social Policies
c. Labor market policies
4. The national government should enhance education
(through information dissemination and developing
analytical skills, critical thinking, and decision making)
9
PPS Policy Statement
and other training policies that respond to the needs of
working children and those who are at risk.
5. The national government should provide opportunities
for specialized training of inspectors of child labor.
6. The national government should increase social
spending and budget allocation to basic social services.
7. The national government should enjoin the participation
of private groups, business sectors, and civic
organizations.
Roles of the Local Government
1. Local governments should develop local laws or
ordinances that are in support of the national
government’s effort at eliminating the worst forms of
child labor.
2. Local governments should provide mechanisms for
improving implementation of national legislation.
3. Local governments should set up mechanisms for
detecting, monitoring, reporting, and providing action
against the worst forms of child labor.
4. Local governments should provide social support and
economic opportunities (through training of adults,
micro-finance, other credit schemes, establishment of
sustainable small industries, and alternative livelihood
programs) to families who are vulnerable to the worst
forms of child labor.
5. Local governments should enforce and implement the
law.
6. Local governments should provide educational and
training opportunities and alternatives to children who
are at risk of and engage in child labor.
7. Local governments should encourage community
involvement and social mobilization through local
advocacy for the prevention of child labor.
8. Local governments should provide free rescue and
psychosocial recovery and social reintegration services
to child laborers.
9. Local governments should provide litigation services
to victims of child labor and child economic
exploitation.
Roles of the Physician and other Health Workers
1. All physicians must be aware of the laws relevant to
child labor.
2. Physicians are encouraged to include as part of the
medical school curriculum and/or residency training
laws and other information relevant to child labor.
3. The physician should detect and report to the proper
authorities any child suspected of engaging in child labor.
4. The physician should counsel the parents of child/
children suspected of engaging in child labor regarding
the immediate hazards and long-term consequences of
child labor.
5. The physician should provide free medical services to
10
Child Labor
children engaged in child labor.
6. The physician should conduct free annual or semi-
annual medical check-ups for identified child laborers
and other members of their families.
Roles of the Parents
1. The parents should ensure that their child/children does
not/do not engage in unacceptable (according to RA
9231) forms of child labor.
Document prepared by the Committee on Policy
Statements
Chairperson: Carmencita D. Padilla, MD, MAHPS
Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma
Makalinao, MD
Members: Nerissa Dando, MD; Joselyn Eusebio, MD;
Edilberto Garcia, Jr., MD; Ramon Severino MD
Advisers: Joel Elises, MD; Salvacion Gatchalian, MD;
Genesis Rivera, MD; Jocelyn Yambao-Franco, MD
Research Associates: Maria Theresa H. Santos, MD; Gloria
Nenita V. Velasco, MD
EXPERT REVIEWERS
Department of Labor and Employment Bureau of Women
and Young Workers
Chita G. Cilindro (Director)
Department of Health National Center for Disease
Prevention and Control
Yolando E. Oliveros, MD, MPH (Director IV)
Department of Social Welfare and Development
Gemma Gabuya (Social Welfare Officer V)
Round Table Discussion Participants
16 October 2007
Department of Labor and Employment Bureau of Women
and Young Workers - Chita G. Cilindro (Director)
Department of Labor and Employment - Ruby Dimaano
Department of Health National Center for Disease
Prevention and Control, Family Health Office – Rodolfo
Albornoz, MD (Medical Specialist III)
Department of Social Welfare and Development – Nicamil
K. Sanchez (Social Welfare Officer IV)
Liga ng mga Barangay sa Pilipinas – Rudenio Eduave
(Director for Organizational Development)
Child Labor PPS Policy Statement

ACKNOWLEDGEMENTS
The committee would like to acknowledge the following
for their contribution:
Department of Labor and Employment Bureau of Women
and Young Workers - Chita G. Cilindro (Director)
Department of Labor and Employment - Ruby Dimaano
Department of Health National Center for Disease
Prevention and Control - Yolando E. Oliveros, MD, MPH
(Director IV)
Department of Health National Center for Disease
Prevention and Control, Family Health Office – Rodolfo
Albornoz, MD (Medical Specialist III)
Department of Social Welfare and Development - Gemma
Gabuya (Social Welfare Officer V)
Department of Social Welfare and Development – Nicamil
K. Sanchez (Social Welfare Officer IV)
Liga ng mga Barangay sa Pilipinas – Rudenio Eduave
(Director for Organizational Development)
REFERENCES
1. DOLE Primer. “Labor in the Philippines.” Available at
http://www.dole.gov.ph/primers/rightswyw.htm
2. UNICEF Fact Sheet.
3. 2001 National Statistics Office Survey on Working
Children
4. Department of Labor and Employment. “The Child
Labor Situation in the Philippines.” Available at http://
www.bwyw.dole.gov.ph/CL%20Situation.htm.
Accessed on October 10, 2006.
5. Gomez C. “RP has 4 million working children.” Visayan
Daily Star. 31 March 2006. Available at http://
w w w. v i s a y a n d a i l y s t a r. c o m / 2 0 0 6 / M a r c h / 3 1 /
topstory7.htm.
6. World Children Organization. Available at http://
world_children.org/WCO%20web%20images/
homepage/phil_cond1.htm.
7. Sardaña MC. “Combating Child Labor in the
Philippines.” Prepared for Asian Development Bank
Institute’s Seminar on Social Protection for the Poor in
Asia and Latin America. 25 October 2002, Manila.
8. ILO Convention No. 138. Available at http://ohchr.org/
english/law/pdf/ageconvention.pdf. Accessed on
September 11, 2007.
9. ILO Convention No. 182. Available at http://
www.ilo.org/public/english/standards/relm/ilc/ilc87/
com-chic.htm. Accessed on September 11, 2007.
10. de Boer J. “Sweet Hazards: Child labor on sugarcane
plantations in the Philippines.” Terre des Hommes
Netherlands. 2005.
11. Republic Act 9231. “An Act Providing for the
Elimination of the Worst Forms of Child Labor and
Affording Stronger Protection for the Working Child,
Amending for this Purpose Republic Act No. 7610. As
Amended, Otherwise Known as the ‘Special Protection
of Children Against Child Abuse, Exploitation, and
Discrimination Act.’” Available at http://
www.ops.gov.ph/records/ra_no9231.htm. Accessed on
September 11, 2007.
12. Reactions to the Policy Statement “Child Labor” drafted
by the Philippine Pediatric Society, Inc. Department of
Social Welfare and Development. October 2007.

DISCLAIMER:
The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision
of quality health care to children. The recommendations contained in this publication do not dictate an exclusive
course of procedures to be followed but may be used as a springboard for the creation of additional policies.
Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and
advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences
in the specific approach. All information is based on the current state of knowledge. Changes may be made in this
publication at any time.

11
xviii
 PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association
In the Service of the Filipino Child

PPS Policy Statements Series 2009 Vol. 1 No. 3

Infant Walkers
Philippine Pediatric Society, Inc.

Infant walkers are commonly employed by parents nowadays. Recent studies have found
that infant walkers may put children at risk for accidents and minor injuries as well as cause
a delay in motor development. This policy presents the advantages and disadvantages of
infant walker use as well as recommendations for its use.

Keywords: infant walkers, accidents, minor injuries

URL: http://www.pps.org.ph/policy_statements/infant_walkers.pdf

BACKGROUND
Infant walkers are commonly used mobile infant carriers today.
They allow a pre-ambulatory infant to sit in a suspended seat
attached to a circular rim standing on wheels. The device gives
the infant precocious locomotion.1-3 Walkers are sometimes
equipped with a plastic table or hanging toys that keep the
infant entertained while seated. Some are equipped with a
braking mechanism whereas others are foldable and can be
easily stowed.1
walker assisted infants initially had abnormal gait when they
started walking independently.1 Aside from delayed motor
development, contractures of the calf muscles and motor
development mimicking spastic diaparesis may also appear.2,8
Moreover, walkers make infants more prone to accidents
such as falls, burns, poisonings, submersions, suffocation
and even death.1,4-6,10-21 All of these accidents are attributed
to the increased range and speed of infants when riding the
walker.

Walkers are employed by parents for various reasons: to keep
their infant preoccupied while they are doing other things, to
hold their children during feeding, to keep their children quiet
and happy, to aid the infant in strengthening their legs and to
help infants walk at an earlier age.1,2,4-6 However, recent studies
have shown that infant walkers are not beneficial to children
and are actually a danger to them.
Several studies have shown that contrary to popular belief,
walkers do not aid infants to walk at an earlier age but can
even delay their motor and mental development.1,2-9 One study
showed that walker-experienced infants scored lower on
Bayley scales of mental and motor development compared to
non-walker experienced.1,3 Another study showed that walker
experienced infants had abnormal Denver Developmental
Screening Test Results9 while another study showed that
Falls. Inside a walker, the speed of the infant can reach up
to 3 feet/sec, and even with a guardian present, this speed
may be too fast to catch a falling child. The speed and
acceleration endowed to an infant when riding a walker may
cause fatal injury from falls even at low heights. Literature
has shown that falls from stairs occur in 75 – 96% of
cases.1,4,5,12,18-20 Some of these are severe, some cause facial
injuries, majority cause head injuries and rarely, fatalities.1,4-
6,10-20
Although some stairs are gated and some walkers are
equipped with braking mechanisms that stop the carriage
when there are changes in elevation, it has been found that
these are not enough to sufficiently decrease the frequency
of falls in infants.1
Burns and Poisonings. Infants riding a walker may be more
prone to both burn injuries and poisoning due to increased

13
PPS Policy Statement
access to the kitchen and other dangerous areas in the house.16-
21
Reported burn injuries were contact and scald burns, some
severe enough to require resuscitation and skin grafting. It
has been reported that the incidence of thermal injury
associated with baby walker use remains at high levels despite
increased safety measures.17,18,21
Submersions and Suffocations. Despite the swimming pool
being fenced-in, there have been reports of submersion and
drowning of infants on walkers. There was also a report of
submersion in a toilet bowl by an infant riding a walker.
Likewise, there was also a report of infant suffocation while
inside the walker when the infant’s neck was caught in between
the walker tray.1
Minor Injuries. These injuries include pinch injuries to the
infant’s fingers and toes, abrasions, contusions, lacerations,
extremity fractures and other soft tissue injuries.1,4-6,12,17-20
Many countries have realized the danger that walkers pose to
their children and, thus, started creating policies that will help
curb this rising problem. Such policies include
recommendations of stationary walkers and playpens as
alternative to mobile infant walkers, guidelines that regulate
the manufacture of safer walkers, withdrawal of mobile
walkers from the market and banning of walker
production.2,4,6,18 In 1997, the American Society for Testing
and Materials (ASTM) created voluntary guidelines and
standards on the manufacture of infant walkers.4 Some of these
include a braking mechanism for the walker and a requirement
that the walker’s width be greater than 36 inches (the width
of an average door).1 Likewise, New South Wales, Australia
has set the 2000 baby walker regulation, which required a
specified level of stability and a gripping mechanism to stop
the walker at the edge of the step.22 All of these moves were
noted to decrease the number of infant walker-related
injuries.4,22
Another means employed is the education of doctors, nurses,
midwives and other health personnel regarding the dangers
of walker use which they then share with the parents and
guardians of the children.2,5,6,10,21-28 This was done in the United
Kingdom, Singapore, US, Canada and other developed
countries. It was found that parental knowledge of the dangers
associated with baby walkers may be effective in reducing
baby walker possession and use.10,23-26,28 However, this only
limited the frequency of baby walker-related accidents to some
extent and many still believe that banning walkers from the
market and recalling existing walkers would be more
effective.3,7,8,18,21,22,27,28
In the Philippines, there is very little awareness on the adverse
effects of walker use. Many still employ infant walkers with
the belief that these aid their children to walk earlier and faster
14
Infant Walkers
without realizing the danger that they pose. Likewise, many
still think that walkers are safe for their children. Both the
Philippine government and society have made no moves to
educate the public on the effects of walker use. Infant walkers
have been in use for many years now and it is only recently
that many are realizing the dangers that they pose. Indeed,
this is something that deserves attention both from the
government and the health sector.
RECOMMENDATIONS
Roles of the Government
1. The government should create guidelines and safety
standards in the manufacture and import of infant walkers,
if not completely ban walkers in the country.
2. The government should launch a media campaign that
informs the public of the disadvantages of infant walkers
and discourages its use.
3. The government should aid in the education of doctors,
midwives and other health personnel on the disadvantages
of infant walker use.
4. The government should ban the use of walkers in hospitals
and approved child care facilities.
5. The government should initiate and support researches
regarding the benefits, disadvantages and safety of infant
walker use in the Philippine setting.
Roles of Physicians and Health Care Personnel
1. Physicians and health care personnel should educate
parents on the hazards of infant walker use.
2. Physicians and health care personnel should conduct
researches that will elucidate further the effects and
disadvantages of infant walker use.
3. Physicians and health care personnel should make sure
that walkers are not used in their clinics and other child
health care facilities.
Roles of Parents
1. Parents should be informed and should read and research
on the hazards of infant walker use.
2. If parents choose to use walkers, they should select a
walker that meets the standards set by the government.
Document prepared by Committee on Policy Statements:
Chairperson: Carmencita D. Padilla, MD, MAHPS
Co-chairpersons: Cynthia Cuayo-Juico, MD and Irma R.
Makalinao, MD
Members: Nerissa M. Dando, MD; Joselyn A. Eusebio, MD;
Edilberto B. Garcia, Jr., MD; Ramon C. Severino, MD
Advisers: Joel S. Elises, MD; Salvacion R. Gatchalian, MD;
Genesis C. Rivera, MD; Jocelyn J. Yambao-Franco, MD
Research Associates: Maria Theresa H. Santos, MD and Gloria
Nenita V. Velasco, MD
Infant Walkers
EXPERT REVIEWER
Lead reviewer: Joselyn A. Eusebio, MD
expert reviewer: Philippine Pediatric Society Committee on
____
Rommel Crisenio M. Lobo, MD
REFERENCES
1. “Injuries associated with infant walkers.” American
Academy of Pediatrics: Committee on Injury and Poison
Prevention. Pediatrics. Vol. 108, No. 3. September 2001.
Pp. 790 – 792.
2. Hadzagic – Catibusic F, Gavrankapetanovic I, Zubcevic
S, Meholjic A, Rekic A, Sunjic M. “Infant walkers: the
prevalence of use.” Medicine Archives. Vol. 58, No. 3.
2004. Pp. 189 – 190.
3. Siegel AC, Burrows RV. “Effects of baby walkers on
motor and mental development in human infants.” Journal
of Developmental and Behavioral Pediatrics. Vol. 20, No.
5. October 1999. Pp. 355 – 361.
4. Shields BJ, Smith GA. “ Success in the prevention of
infant walker – related injuries: an analysis of national
data, 1990 – 2001. Pediatrics. Vol. 117, No. 3. March
2006. Pp. e452 – 459.
5. Santos Serrano L, Paricio Talavero JM, Salom Perez A,
Grieco Burucua M, Martin Ruano J, Benlloch Muncharaz
MJ, Llobat Estelles T, Beseler Soto B. “Patterns of use ,
popular beliefs and proneness to accidents of a baby
walker. Bases for health information campaign.” An Esp
Pediatrica. Vol. 44, No. 4. April 1996. Pp. 337 – 340.
6. Al-Nouri L, Al-Isami S. “Baby walker injuries.” Annals of
Tropical Pediatrics. Vol. 26, No. 1. March 2006. Pp. 67 –
71.
7. Burrows P, Griffiths P. “Do baby walkers delay the onset
of walking in young children?” British Journal of
Community Nursing. Vol. 7, No. 11. November 2002.
Pp. 581 – 586.
8. Engelbert RH, van Empelen R, Scheurer ND, Helders
PJ, van Nieuwenhuizen O. “Influence of infant walkers
on motor development: mimicking spastic diplegia?”
European Journal of Pediatric Neurology. Vol. 3, No. 6.
1999. Pp. 273 – 275.
9. Thein MM, Lee J, Tay V, Ling SL. “Infant walker use,
injuries, and motor development.” Injury Prevention. Vol.
3, No. 1. March 1997. Pp. 63 – 66.
10. Wishon PM, et. al. “Hazard patterns and injury prevention
with infant walkers and strollers.”
11. “Deaths associated with infant carriers – United States,
1986 – 1991. MMWR Morbidity and Mortality Weekly
Report. Vol. 41, No. 16. April 24, 1992. Pp. 271 – 272.
12. Dedoukou X, Spyridopoulos T, Kedikoglou S, Alexe DM,
Dessypris N, Petridou E. “Incidence and risk factors of
PPS Policy Statement
fall injuries among infants: a study in Greece.” Archives
of Pediatric and Adolescent Medicine. Vol. 158, No. 10.
October 2004. Pp. 1002 – 1006.
13. Watson WL, Ozanne – Smith J. “The use of child safety
restraints with nursery furniture.” Journal of Pediatric
Child Health. Vol. 29, No. 3. June 1993. Pp 228 – 232.
14. Leblanc JC, Pless IB, King WJ, Bawden H, Bernard –
Bonnin AC, Klassen T, Tenenbein M. “Home and safety
measures and the risk of unintentional injury among
young children: a multicenter case – control study.”
CMAJ. Vol. 175, No. 8. October 10, 2006. Pp. 883 – 887.
15. Emanuelson I. “How safe are childcare products, toys
and playground equipment? A Swedish analysis of mild
brain injuries at home and during leisure time 1998 –
1999. Injury Control and Safety Promotion. Vol. 10, No.
3. September 2003. Pp. 139 – 144.
16. Mroz LS, Krenzelok EP. “Examining the contribution of
infant walkers to childhood poisoning.” Vet Hum
Toxicology. Vol. 42, No. 1. February 2000. pp. 39 – 40.
17. Cassell OC, Hubble M, Milling MA, Dickson WA. “Baby
walkers – still a major cause of infant burns.” Burns. Vol.
23, No. 5. August 1997. Pp. 451 – 453.
18. Smith GA, Bowman MJ, Luria Jw, Shields BJ. “Baby
walker – related injuries continue despite warning labels
and public education.” Pediatrics. Vol. 100, No. 2. August
1997. P. E1.
19. Claydon SM. “Fatal extradural hemorrhage following a
fall from a baby bouncer.” Pediatric Emergency Care.
Vol. 12, No. 6. December 1996. Pp. 432 – 434.
20. Petridou E, Simou E. Skondras C, Pistevos G, Lagos P,
Papoutsakis G. “Hazards of baby walkers in a European
context.” Injury Prevention. Vol. 2, No. 2. June 1996.
Pp. 118 – 120.
21. Sendut IH, Tan KK, Rivara F. “Baby walker associated
scalding injuries seen at University Hospital Kuala
Lumpur.” Medical Journal Malaysia. Vol. 50, No. 2. June
1995. Pp. 192 – 193.
22. Thompson PG. “Injury caused by baby walkers: the
predicted outcomes of mandatory regulations.” Medical
Journal of Australia. Vol. 177, No. 3. August 5, 2002. Pp.
147 – 148.
23. Kendrick D, Illingworth R, Woods A, Watts K, Collier
J, Dewey M, Hapgood R, Chen CM. “Promoting child
safety in primary care: a cluster randomized controlled
trial to reduce baby walker use.” British Journal of
General Practice. Vol. 55, No. 517. August 2005. pp.
579 – 580.
24. Tan NC, Lim NM, Gu K. “Effectiveness of nurse
counselling in discouraging the use of the infant walker.”
Asia Pacific Journal of Public Health. Vol. 16, No. 2. 2004.
Pp. 104 – 108.
25. Rhodes K, Kendrick D, Collier J. “Baby walkers:
pediatricians’ knowledge, attitudes, and health
promotion.” Archives of Diseases in Childhood. Vol. 88,
No. 12. December 2003. Pp. 1084 – 1085.
15
PPS Policy Statement Infant Walkers

26. Conners GP, Veenema TG, Kavanagh CA, Ricci J,
Callahan CM. “Still falling: a community – wide infant
walker injury prevention initiative.” Patient Educ
Couns. Vol. 46, No. 3. March 2002. Pp. 169 – 173.
27. Kendrick D, Marsh P. “Babywalkers: prevalence of use
and relationship with other safety practices.” Injury
Prevention. Vol. 4, No. 4. December 1998. Pp. 295 –
298.
28. Morrison CD, Stanwick RS, Tenenbein M. “Infant
walker injuries persist in Canada after sales have
ceased.” Pediatric Emergency Care. Vol. 12, No. 3. June
1996. Pp. 180 – 182.

DISCLAIMER:
The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision
of quality health care to children. The recommendations contained in this publication do not dictate an exclusive
course of procedures to be followed but may be used as a springboard for the creation of additional policies.
Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and
advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences
in the specific approach. All information is based on the current state of knowledge. Changes may be made in this
publication at any time.

16
 PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association
In the Service of the Filipino Child

PPS Policy Statements Series 2009 Vol. 1 No. 4

Caffeine and Children

Philippine Pediatric Society, Inc.

Caffeine is both a naturally occurring substance and an additive in many foods, beverages,
and medicines. It is a known stimulant that mainly influences the central nervous system but
has effects on other body systems. Its consumption is widespread due to its easy accessibility
and availability through sodas, chocolate, and coffee, owing to the spread of coffee
establishments in the area. Its specific effects on children have been relatively less studied.
This policy statement looks into local consumption of caffeine-containing foods and drinks,
its effects, and guidelines that have been set by other countries. The Philippine Pediatric
Society, Inc. recommends limiting caffeine consumption by children.

Keywords: caffeine, xanthine derivatives, addiction, tea, coffee

URL: http://www.pps.org.ph/policy_statements/caffeine_and_children.pdf

BACKGROUND central nervous system. Caffeine’s effects are dose-related and

Caffeine has been used as early as the Stone Age when ancient
peoples discovered that chewing seeds, bark, and leaves of certain
plants eased fatigue, stimulated awareness, and elevated mood.1,2
For thousands of years, it has been used in a variety of forms
such as coffee, tea, chocolate, yerba maté, and guarana berries
among others. 3 Caffeine is the most widely consumed
psychoactive substance, its consumption being estimated at
120,000 tons per annum.1 It has also been added to a variety of
carbonated and energy drinks and medicines, such as
decongestants, analgesics, stimulants, and appetite suppressants.4
(See Appendix) Children’s exposure to caffeine is largely via
carbonated drinks, chocolate, tea, and coffee (especially in
urbanized areas) through the deluge of coffee franchises.
In a study on beverage caffeine intake in young children in
Canada and USA, it was determined that American children
consumed more caffeinated beverages at 56% compared to
Canadian children at 36%. Canadian children consumed
approximately half the amount of caffeine (7 vs. 14 mg/day).
It was concluded, however, that caffeine intake from
caffeinated beverages remained well within safe levels for
consumption by young children.5
Caffeine is a xanthine derivative and its effects are mediated
through its action on the cerebral cortex and brain stem of the
most of its undesirable effects are at greater doses. At doses
of 100-200 mg, caffeine may increase alertness and
wakefulness, promote faster and clearer flow of thought and
better general body coordination, and may produce loss of
fine motor control and result in dizziness. 6,7 However doses
of more than 500-600 mg can cause restlessness, anxiety,
irritability, muscle tremors, sleeplessness, headaches, nausea,
diarrhea or other gastrointestinal problems, and abnormal heart
rhythms.8 Caffeine stimulates the heart, dilates vessels, causes
bronchial relaxation, and increases gastric acid production.7
Its other metabolic effects include releasing fatty acids from
adipose (fatty) tissue and affecting the kidneys (resulting in
increased urination) which could lead to dehydration.9 It is
important to note that caffeine also fits the definition of an
addictive substance, with withdrawal symptoms, an increase
in tolerance over time, and physical cravings.7
Caffeine poisoning from consuming excessive amounts has
occurred in other countries.10,11 The symptoms of caffeine
poisoning in infants include very tense muscles alternating
with overly relaxed muscles, rapid, deep breathing, nausea
and/or vomiting, rapid heartbeat, shock, and tremors.12
Though the effects of caffeine have been studied for years,
research into its effect on children is a relatively untouched
area. A recent study done in Harding University, Arkansas,

17
PPS Policy Statement
USA was the first to investigate the effects of caffeine on both
cardiovascular and metabolic responses to exercise in healthy
boys and girls. The study was done on 52 seven to nine-year
old boys and girls, each randomly receiving a placebo and a
caffeinated drink twice each on four separate days. The results
revealed that caffeine acutely elevated both resting and
exercise blood pressure, but acutely reduced heart rate in boys
and girls given a moderate to high dose of caffeine an hour
before exercise. Caffeine was found to have no effect on
metabolism, and there were no significant differences found
between boys and girls.13
In the United States, a report by the National Center for
Addiction and Substance Abuse at Columbia University found
that young women aged 8 to 22 who drank coffee were more
likely to smoke and drink alcohol, and to do so at an earlier
age than non-coffee drinkers and their male counterparts. The
study called caffeine “a little known risk factor” for substance
abuse and warned that the glamorizing of addictive substances
had contributed to this problem.14 In a study done on caffeine
dependence in 36 adolescents, it was determined that there
was no significant difference in the amount of caffeine
consumed daily by caffeine dependent versus non-dependent
teenagers.15
In a study done on 275 students in Italy in 2006, the prevalence
and related disability of multiple addictions were assessed. In
this population, behavioral addictions were multiple, a source
of disability, and were related to substance. However, whether
this is a temporary phenomenon among adolescents or a
reliable marker for the future development of substance abuse
needs to be clarified.16
There has also been concern on the possible negative effects
of caffeine on bone growth of children. A cohort study
conducted by Lloyd et al. was done to determine whether
dietary caffeine consumed by American white females between
ages 12 to 18 affected total body bone mineral gain during
ages 12 to 18 or affected hip bone density measured at age
18. It was determined that dietary caffeine intake at levels
presently consumed by American white, teenage women was
not correlated with adolescent total bone mineral gain or hip
bone density at age 18.17
A meta-analysis was conducted by Hughes and Hale on the
behavioral effects of caffeine and other methylxanthines on
children. Acute exposure to or intake of high doses (>3 mg/
kg) of caffeine in children who consumed little caffeine
produced negative subjective effects (e.g. nervousness,
jitteriness, stomachaches, and nausea). Caffeine appeared to
slightly improve vigilance performance and decreased reaction
time in healthy children who habitually consumed caffeine.18
The acute effects of caffeine on learning, performance, and
anxiety were investigated in 21 children through a double-
18
Caffeine and Children
blind placebo-controlled crossover design. In the small sample
size, there was an indication that caffeine enhanced
performance on a test of attention and on a motor task. The
participants reported feeling less “sluggish” but somewhat
more anxious.19
Cases of rare reactions to caffeine intake including tics20 and
urticaria21 have been documented.
Aside from the undesirable effects that children may
experience with excessive caffeine ingestion, there are other
concerns that adults need to be aware of. Excessive intake of
carbonated drinks may lead to obesity, nutritional deficiencies,
and dental caries.22 Caffeine addiction may also put patients
at risk for tooth wear, such as attrition, erosion, and abrasion.23
In addition, there are certain medications that interact
negatively with caffeine. The antibiotics ciprofloxacin and
norfloxacin may increase the length of time caffeine remains
in the body and may amplify its effects. Theophylline has some
caffeine-like effects and its concentration may increase in the
blood when taken with caffeine-containing food or beverages.
Ephedra (or ma-huang), an herbal dietary supplement, has
already been banned due to health concerns in the USA but
may still be present in herbal teas. Its ingestion in combination
with caffeine may be risky.8
In a 2008 retrospective assessment done in the Virginia Adult
Twin Study of Psychiatric and Substance Use Disorders, it
was concluded that individual differences in psychoactive
substance use (in this case alcohol, caffeine, cannabis, and
nicotine), in terms of initiation and early patterns of use, were
strongly influenced by social and familial environmental
factors while later use was more strongly influenced by genetic
factors.24 This underscores the importance that parents and
schools play in prevention and cessation counseling.
However, other beverages that contain caffeine, such as tea
and coffee, may have other beneficial effects. The beneficial
effects of coffee are a direct result of its higher caffeine content.
Its regular intake may reduce the risk of Parkinson’s disease,
type 2 diabetes25, colon cancer, liver cirrhosis, hepatocellular
carcinoma26, and gallstones.27,28 It may also serve as a powerful
aid in enhancing athletic endurance and performance and help
manage asthma and headaches. Furthermore, coffee contains
antioxidants (e.g. chlorogenic acid and tocopherols) and
minerals, such as magnesium, that may improve insulin
sensitivity and glucose metabolism. Lastly, trigonelline in
coffee has anti-bacterial and anti-adhesive properties that may
help prevent dental caries.27
To what extent an individual will be affected will depend on
his/her sensitivity to the substance and his/her sensitivity, in
turn, will depend on body mass, history of caffeine use, and
stress. Those with lower body masses (e.g. children) will
experience the effects of caffeine sooner than those with
Caffeine and Children
higher body masses (e.g. adults). Those with regular caffeine
intake will be less susceptible to experiencing caffeine’s
negative effects than those with irregular caffeine intake.
And all types of stress can increase a person’s sensitivity to
caffeine, e.g. psychological stress or heat stress. Age,
smoking habits, drug or hormone use, and other health
conditions (e.g. anxiety disorders) are additional factors that
need to be considered.8
In the USA, there are no specific guidelines for limiting
caffeine intake. Moderate coffee drinking of 1-2 cups per day
does not seem to be harmful according to the American Heart
Association.9 Health Canada, however, has the following
recommendations for maximum caffeine intake levels for
children:
Children* 4 - 6 years 45 mg/day
7 - 9 years 62.5 mg/day
10 - 12 years 85 mg/day
* Using the recommended intake of 2.5 milligrams per
kilogram of body weight per day and based on average body
weights of children (Health and Welfare Canada, 1990), based
on “behavioral effects”. 29
In the Philippines, caffeine is considered a miscellaneous food
additive in cola type beverages and its maximum level of use
is limited to 200 ppm.30 At present, there are no existing
specific guidelines on limiting caffeine intake for children.
RECOMMENDATIONS
Roles of the Government
1. The government should implement laws that mandate
labeling of all food, beverage, and medicines that
contain caffeine and the level of caffeine found in these
products.
2. The government should strengthen and implement
programs to promote healthy diet and alternative
options to intake of caffeine-containing foods and
beverages.
3. Increase awareness of the public, through the Department
of Health and DOH accredited hospitals, including
schools on the effects of caffeine in children.
4. To encourage the coffee selling establishments to include
a warning or caution (posters, signs) on the negative
effects of caffeine on children.
Roles of Food, Beverage, and Medicine Manufacturers
1. Food, beverage, and medicine manufacturers should
properly label their products that contain caffeine and the
levels at which it is found in the product.
PPS Policy Statement
Note : Labeling may not be enough. It should include :
Caffeine may be “habit forming,” “may cause increase
in heart rate,” “insomnia,” or even “NOT
RECOMMENDED FOR CHILDREN or
CONTRAINDICATED IN CHILDREN WITH
MEDICAL CONDITIONS,” “OR CONSULT YOUR
DOCTORS ON THE SAFETY OF CAFFEINE IN
CHILDREN.”
Roles of Physicians
1. Physicians should educate parents and caregivers on the
effects of caffeine, the products that contain them, and
ways in which its intake could be reduced and/or
avoided.
2. Physicians should educate parents and caregivers on food
and beverage products that are energy rich but
nutritionally dense (e.g. fresh fruit juices, milk, etc.) in
place of softdrinks and energy drinks.
3. Physicians should be vigilant in prescribing medications
that have adverse drug interactions with caffeine-
containing food and beverages, especially if their
pediatric patients are consuming diets containing such
items.
Roles of Parents
1. Parents should educate their children on the effects of
caffeine and the products that contain them.
2. Parents should encourage the reduction and/or avoidance
of caffeine in their children’s diets.
3. Parents should encourage their children to consume food
and beverage products that are energy rich but
nutritionally dense (e.g. fresh fruit juices, milk, etc.).
4. Parents should inquire with their children’s primary
physician if any of their child’s medications (whether
prescription or over-the-counter) contain caffeine and the
level at which it is found in the medication.
5. Parent should aim to reduce/avoid administering
medication containing caffeine to their children unless
otherwise strongly indicated by their child’s pediatrician/
attending physician.
6. Parents should set examples in the moderate intake of
coffee.
Document prepared by the Committee on Policy
Statements
Chairperson: Carmencita D. Padilla, MD, MAHPS
Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma Makalinao,
MD
Members: Nerissa Dando, MD; Joselyn Eusebio, MD;
Edilberto Garcia, MD; Ramon Severino, MD
Advisers: Joel Elises, MD; Salvacion Gatchalian, MD;
Genesis Rivera, MD; Jocelyn Yambao-Franco, MD
Research Associates: Maria Theresa H. Santos, MD; Gloria
Nenita V. Velasco, MD
19
PPS Policy Statement
ACKNOWLEDGEMENTS
The Committee on Policy Statements recognizes the
contribution of the following:
Dr. Mario Capanzana -- Officer in Charge, Food and
Nutrition Research Institutex
REFERENCES
1. “Caffeine.” Available at http://en.wikipedia.org/wiki/
Caffeine. Accessed on May 7, 2007.
2. Suleman A, Siddiqui NH. “Hemodynamic and
cardiovascular effects of caffeine.” Available at http://
www.priory.com/pharmol/caffeine.htm. Accessed on
May 7, 2007.
3. National Cancer Institute. “Caffeine.” National Cancer
Institute Drug Dictionary. National Institutes of Health.
Available at http://www.cancer.gov/Templates/
drugdictionary.aspx?CdrID=40817. Accessed on May
11, 2007.
4. National Cancer Institute. “Caffeine.” National Cancer
Institute Dictionary of Cancer Terms. National Institutes
of Health. Available at http://www.cancer.gov/
Templates/db_alpha.aspx?CdrID=454809. Accessed on
May 11, 2007.
5. Knight CA, Knight I, Mitchell DC. Abstract. “Beverage
caffeine intakes in young children in Canada and the
US.” Canadian journal of dietetic practice and research:
a publication of Dietitians of Canada. 2006 Summer.
Vol. 67 No. 2. Pages 96-99.
6. “Caffeine.” Available at http://www.stanford.edu/
~johnbrks/theCafe/substance/caffeine.html. Accessed
on May 7, 2007.
7. “Caffeine Effects: The Effects of Caffeine on the Body.”
Available at http://mass-spec.chem.cmu.edu/VMSL/
Caffeine/Caffeine_effects.htm. Accessed on May 11,
2007.
8. Mayo Clinic Staff. “Caffeine: How much is too much?”
8 March 2007. Available at http://www.mayoclinic.com/
health/caffeine/NU00600. Accessed on May 21, 2007.
9. American Heart Association. “Caffeine: AHA
Recommendation.” Available at http://
w w w . a m e r i c a n h e a r t . o r g /
presenter.jhtml?identifier=4445. Accessed on May 21,
2007.
10. Jorens PG, Van Hauwaert JM, Selala MI, Schepens PJ.
Abstract. “Acute caffeine poisoning in a child.”
European journal of pediatrics. October 1991. Vol. 150
No. 12. Page 860.
11. Walsh I, Wasserman GS, Mestad P, Lanman RC.
Abstract. “Near-fatal caffeine intoxication treated with
peritoneal dialysis.” Pediatric emergency care.
December 1987. Vol. 3 No. 4. Pages 244-249.
20
Caffeine and Children
12. Psychology Today Staff. “Caffeine.” Psychology Today.
2002 October 10. Available at http://
www.medicinenet.com/script/main/
art.asp?articlekey=38065. Accessed on May 11, 2007.
13. Turley KR, Gerst JW. Abstract. “Effects of caffeine on
physiological responses to exercise in young boys and
girls.” Medicine and Science in Sports and Exercise.
2006 March. Vol. 38 No.3. Pages 520-526.
14. Needham C. “Sweet but dark: coffee consumption and
teen girls.” Available at http://www.jrn.columbia.edu/
studentwork/cns/2003-06-03/320.asp. Accessed on June
8, 2005.
15. Bernstein GA, Carroll ME, Thuras PD, Cosgrove KP,
Roth ME. Abstract. “Caffeine dependence in teenagers.”
Drug and alcohol dependence. 1 March 2002. Vol. 66
No. 1. Pages 1-6.
16. Pallanti S, Bernardi S, Quercioli L. Abstract. “The
Shorter PROMIS Questionnaire and the Internet
Addiction Scale in the assessment of multiple addictions
in a high school population: prevalence and related
disability.” CNS Spectr. 2006 Dec. Vol. 11 No. 12. Pages
966-974.
17. Lloyd T, Rollings NJ, Kieselhorst K, Eggli DF, Mauger
E. Abstract. “Dietary caffeine intake is not correlated
with with adolescent bone gain.” Journal of the
American College of Nutrition. October 1998. Vol. 17
No. 5. Pages 454-457.
18. Hughes JR, Hale KL. Abstract. “Behavioral effects of
caffeine and other methylxanthines on children.”
Experimental and clinical psychopharmacology.
February 1998. Vol. 6 No. 1. Pages 87-95.
19. Berstein GA, Carroll ME, Crosby RD, Perwien AR, Go
FS, Benowitz NL. Abstract. “Caffeine effects on
learning, performance, and anxiety in normal school-
age children.” Journal of the American Academy of
Child and Adolescent Psychiatry. March-April 1994.
Vol. 33 No. 3. Pages 407-415.
20. Davis RE, Osorio I. Abstract. “Childhood caffeine tic
syndrome.” Pediatrics. June 1998. Vol. 101 No. 6. Page
E4.
21. Caballero T, Garcia-Ara C, Pascual C, Diaz-Pena JM,
Ojeda A. Abstract. “Urticaria induced by caffeine.”
Journal of investigational allergology & clinical
immunology : official organ of the International
Association of Asthmology (INTERASMA) and
Sociedad Latinoamericana de Alergia e Inmunología.
May-June 1993. Vol. 3 No. 3. Pages 160-162.
22. Gavin, ML, ed. “Caffeine and your Child.” 2005
January. Available at http://www.kidshealth.org/parent/
nutrition_fit/nutrition/caffeine.html. Accessed on
January 29, 2007.
23. Young WG. Abstract. “Tooth wear: diet analysis and
advice.” Int Dent J. 2005 April. Vol. 55. No. 2. Pages
68-72.
24. Kendler KS, Schmitt E, Aggen SH, Prescott CA.
“Genetic and environmental influences on alcohol,
caffeine, cannabis, and nicotine use from early
adolescence to
Caffeine and Children PPS Policy Statement

middle adulthood.” Archives of General Psychiatry. 2008
June. Vol. 65. No. 6. Pages 674-682.
25. Salazar-Martinez E, Willett WC, Ascherio A, Manson
JE, Leitzmann MF, Stampfer MJ, Hu FB. “Coffee
Consumption and Risk for Type 2 Diabetes Mellitus.”
Annals of Internal Medicine. 2004. Vol. 140. Pages 1-
8.
26. Larsson SC, Wolk A. Abstract. “Coffee consumption
and risk of liver cancer: a meta-analysis.”
Gastroenterology. May 2007. Vol. 132 No. 5. Pages
1740-1745. Epub 24 March 2007.
27. Nazario B., ed. “Coffee: The New Health Food?”
WedMD. Available at http://www.somalibantu.com/
Health%20Coffee.htm. Accessed on June 8, 2005.
28. Higdon JV, Frei B. Abstract. “Coffee and health: a
review of recent human research.” Critical reviews in
food science and nutrition. 2006. Vol. 46 No. 2.
29. Health Canada. “Fact Sheet: Caffeine and Your Health.”
Available at http://www.hc-sc.gc.ca/fn-an/securit/facts-
faits/caf/caffeine_e.html. Accessed on May 11, 2007.
30. Administrative Order No. 88-A s. 1984. “Regulatory
Guidelines Concerning Food Additives.” Department
of Health. Republic of the Philippines.

DISCLAIMER:
The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision
of quality health care to children. The recommendations contained in this publication do not dictate an exclusive
course of procedures to be followed but may be used as a springboard for the creation of additional policies.
Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and
advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences
in the specific approach. All information is based on the current state of knowledge. Changes may be made in this
publication at any time.

21
PPS Policy Statement Caffeine and Children

APPENDIX

Item Amount of Item Amount of Caffeine

Mountain Dew 12 ounces 55.0 mg

Coca-Cola, classic and Cherry 12 ounces 34.0 mg
Coke Light 12 ounces 45.0 mg
Pepsi 12 ounces 37.0 mg
7-Up, Sprite, Diet Sprite 12 ounces 0 mg
Brewed coffee (drip method) 8 ounces 135 mg*
Instant coffee 8 ounces 95 mg*
Decaffeinated brewed coffee 8 ounces 5 mg*
Decaffeinated instant coffee 8 ounces 3 mg*
Starbucks Coffee Grande 16 ounces 259 mg
Black tea 8 ounces 40-70 mg*
Green tea 8 ounces 25-40 mg*
Decaffeinated black tea 8 ounces 4 mg*
Nestea Iced tea 12 ounces 26 mg
Dark chocolate 1 ounce 20 mg*
Milk chocolate 1 ounce 6 mg*
Cocoa beverage 5 ounces 4 mg*
Chocolate milk beverage 8 ounces 5 mg*
* denotes average amount of caffeine. Adapted from www.kids.health.org and
www.mayoclinic.com

22
 PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association
In the Service of the Filipino Child

PPS Policy Statements Series 2009 Vol. 1 No. 5

Medical Certificate for School Entrants

Philippine Pediatric Society, Inc.
Philippine School Health Officers Association
Philippine Society of Pediatric Cardiology
Department of Education

A medical certificate is required by most schools before a student is allowed admission.

However, in the Philippines there is no standard protocol for the health assessment of a child
entering school. This policy describes the benefits and limitations of such an examination as
well as the elements required for a satisfactory medical certification of school – aged child.

Keywords: medical certificate, school entrant medical exam

URL: http://www.pps.org.ph/policy_statements/medical_certificate.pdf

BACKGROUND
A school entrant is a child, adolescent, or young adult who is
about to enter nursery, Grade 1 of elementary school, Grade 6
of middle school, first year of high school, or first year of
college or a vocational course. In addition, a school entrant
may be a transferee student regardless of the grade or year
level he/she will be entering.
Philippine situation
Schools generally require that their students undergo a physical
examination and medical evaluation upon enrollment. This
medical certification indicates whether the child is fit to enroll
or requires further evaluation. It is issued after a general health
assessment by either the child’s primary care physician or the
school physician. In the Philippines, there are no existing
guidelines/protocols or laws mandating this. Not all private
schools require such certification prior to admission. The
pending Magna Carta of Students requires that school
authorities endeavor to provide free annual physical check-
ups to students.1
International situation
In the USA, schools also require what is known as a school
entrant medical examination, school entry physical, or school
entry health assessment. The extent to which it is done and its
coverage varies from state to state. The American Academy
of Pediatrics (AAP) has endorsed the importance of
comprehensive periodic health assessments. These are to be
done beginning at 3 years of age with attention to school health
issues. Several different types of routine health assessments
are performed in US schools. These assessments include health
screening (which is mandatory in many US schools), such as
screening for vision, hearing, blood pressure, and scoliosis.
Students with detected abnormalities are then referred to their
medical homes for further assessment and possible treatment.
Further actions and/or follow-up are conveyed to the school
nurse for documentation purposes.2
Benefits
The two main purposes of this medical evaluation is to
identify the high-risk population in the student body and
fulfill a public health service role. Furthermore, it allows
the physician to fully examine and interview the child for
any problems and be up-to-date with the child’s development.
Physicians may also inquire about previous consultations
with other physicians, and establish/enhance communication
with the child and his/her parents. At the same time, it
provides opportunities for parents to gain information,
support, and advice. This way, any potential problems may
be dealt with expediently.3

23
PPS Policy Statement
Limitations
There are issues, however, regarding the effectiveness and
efficiency of a routine school entry medical examination. A meta-
analysis was done of research conducted in the United Kingdom
between 1962 and 1996 on the effectiveness and efficiency of
the school entry medical examination. It revealed that the data
gathered was inadequate and demonstrated the fragility of the
evidence on which the school entry medical was based.4 In a
study done of 425 low and middle-class school children from
West Jerusalem, 84 % of the unknown conditions were diagnosed
by the nurse either through screening or interview. The researchers
recommended that health screening be performed by the nurses,
the physicians’ examination be discontinued with respect to the
routine health surveillance, and that a report on the health status
of the child be requested from the child’s primary care physician.
This would allow the school physicians’ to allocate time for health
promotion and health education activities.5 The time allotted for
the actual examination is also a limiting factor as the academic
period of the students must be taken into consideration.
Recommended elements
The following are the recommended elements of the medical
interview and physical examination prior to issuing a medical
certificate:
The medical interview
1. Medical history – attention to physical, emotional, or
family problems that might influence school achievement,
previous participation in preschool experiences, new
medical problems, medications
2. Immunization status – dates of previous, updating as
necessary
3. Language, social, and adaptive development – changes
in child’s developmental and psychosocial status, update
on school progress and problems
The physical examination (should be age appropriate and
performed by a physician)
1. Height and weight
2. Blood pressure and heart rate
3. Teeth, gums, tongue, and throat
4. Reflexes
5. Eyes (to include vision), ears (to include hearing), nose,
and skin
6. Heart, lungs, and abdomen
7. Fine-motor development, such as the ability to pick up
small objects or tie shoes
8. Gross-motor development, such as the ability to walk,
climb stairs or jump
9. Spinal alignment for signs of curvature (scoliosis)
10. Genitalia, confirming a normal level of maturation and
checking for hernia, infection and other possible problems
24
Medical Certificate for School Entrants
RECOMMENDATIONS
Roles of the National Government
1. The national government should mandate general health
assessments for school entrants as recommended by
medical authorities and other stakeholders.
Roles of Local Governments
1. Local governments should support schools that require
general health assessments from their school entrants
through local ordinances/laws facilitating collaboration
with local health personnel and facilities.
Roles of the Schools
1. A standardized format of the medical interview and
examination should be agreed upon by all schools that
require a medical certificate for their school entrants.
2. Schools should provide medical access for students, either
through a school physician, pediatrician, or other qualified
primary care physician, that will allow them to obtain a
medical certificate.
Roles of the Physician
1. The physician who is tasked to interview, examine, screen,
and counsel the child should examine her/him individually
rather than in groups to protect confidentiality and the
child’s sense of modesty.2
2. A potential health problem that is detected may be
referred to the patient’s primary care physician for
management/co-management or to appropriate
specialists, if necessary, with proper notification of the
child’s parents.
3. The physician should ensure that adequate time is allotted
to medical evaluations.
Roles of the Parents
1. Parents should consent to medical evaluations that are
necessary prior to a medical certification.2
2. Parents should be present when these medical evaluations
are done. 2
3. Parents should ensure that adequate time for such medical
evaluations will be available for the physician.
Document prepared by the Committee on Policy
Statements
Chairperson: Carmencita D. Padilla, MD, MAHPS
Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma
Makalinao, MD
Members: Nerissa Dando, MD; Joselyn Eusebio, MD;
Edilberto Garcia, Jr., MD; Ramon Severino MD
Advisers: Joel Elises, MD; Salvacion Gatchalian, MD;
Genesis Rivera, MD; Jocelyn Yambao-Franco, MD
Research Associates: Maria Theresa H. Santos, MD; Gloria
Nenita V. Velasco, MD
Medical Certificate for School Entrants PPS Policy Statement

EXPERT REVIEWERS The committee would like to acknowledge the following for
their contribution:
Private School Health Officers’ Association, Inc. Philippine School Health Officers’ Association – Dolores
Ma. Consuelo Z. Garcia, MD, DPACCD (Immediate Past Sepacio, RN
President) Philippine Society of Pediatric Cardiology – Della Gonzales-
Pelaez, MD
Philippine Ambulatory Pediatric Association Department of Education – Ma. Corazon Dumlao, MD (Chief,
Cecilia O. Gan, MD Health Division)

Round Table Discussion Participants

REFERENCES
16 November 2009
Alexander O. Tuazon, MD 1. Senate Bill No. 138. An Act Providing for a Magna Carta
Philippine School Health Officers’ Association - Consuelo Z. for Students. 14th Congress. House of Representatives.
Garcia, MD 2. American Academy of Pediatrics Policy Statement.
Child Neurology Society Philippines, Inc. - Marissa Lukban, School Health Assessments. Committee on School Health.
MD Pediatrics Vol. 105 No. 4 April 2000. Pp.875-7.
Philippine Ambulatory Pediatric Association - Cecilia Gan, 3. Child Health Assessments. Available at http://
MD www.communityindicators.net.au/metadata_items/
Philippine Society of Pediatric Cardiology - Ma. Bernadette child_health_assessments. Accessed on 25 September
A. Azcueta, MD 2007.
4. Barlow J, Stewart-Brown S, Fletcher J. Abstract.
29 November 2007 Systematic review of the school entry medical
Philippine School Health Officers’ Association - Consuelo Z. examination. Arch Dis Child April 1998. Vol. 78. Pp. 301-
Garcia, MD 311.
Child Neurology Society Philippines, Inc. - Susan Andong, 5. Gofin R, Palti H, Benson A. Abstract. The Health Status
MD of School Children and the Effectiveness of the School
Philippine Ambulatory Pediatric Association - Cecilia Gan, Medical Entrance Examination. The European Journal
MD of Public Health. 1991. Vol. 1 No. 2. Pp. 61-64.
6. School age physicals: what to know before you go. Mayo
Clinic. Last updated 1 August 2006. Available at
ACKNOWLEDGEMENTS www.mayoclinic.com. Accessed on 23 September 2007.

DISCLAIMER:
The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision
of quality health care to children. The recommendations contained in this publication do not dictate an exclusive
course of procedures to be followed but may be used as a springboard for the creation of additional policies.
Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and
advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences
in the specific approach. All information is based on the current state of knowledge. Changes may be made in this
publication at any time.

25
xxxii
 PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association
In the Service of the Filipino Child

PPS Policy Statements Series 2009 Vol. 1 No. 6

Pre-Operative Evaluation in Pediatric Patients

Undergoing Surgery and other Major Therapeutic
or Diagnostic Procedures
Philippine Pediatric Society, Inc.
Philippine Society for Pediatric Cardiology
Child Neurology Society of the Philippines
Philippine Society for Pediatric Anesthesia
Philippine Society of Pediatric Surgeons

Abstract. Surgical procedures are always accompanied by risks and complications. To

minimize these, the patient must be evaluated pre – operatively through accurate and adequate
history taking, and physical and laboratory examinations. This policy statement discusses
the risks involved in pediatric surgery and the components and guidelines for preoperative
evaluation in the pediatric population.

Keywords: pre-operative evaluation, medical history, physical examination, laboratory tests,

patient education
URL: http://www.pps.org.ph/policy_statements/pre-operative_evaluation.pdf

BACKGROUND the general population, cardiovascular risk factors still

With the rapid advancements in technology, surgical
procedures have become safer, more sophisticated, and less
invasive. Anesthetic procedures have also been improved and
streamlined. Surgical morbidity and mortality have decreased.
However, despite all these advances, the risks and
complications of surgery still can not be eliminated, they can
only be minimized. Pre – operative risk assessment and
evaluation is the major methodology in minimizing surgical
complications. Pre – operative evaluation is a must for almost
all surgical procedures and medical testing requiring
anesthesia. 1 It is required for all patients undergoing a
diagnostic or therapeutic procedure regardless of the setting
except in the following cases: (1) Healthy patients requiring
nerve blocks, local or topical anesthesia and/or no more than
50% nitrogen oxide, oxygen and no other sedative or analgesic
agents, and (2) Patients receiving sedation analgesia or
conscious sedation.2
It is commonly believed that the greatest risk in adult
surgery is cardiovascular complications, whereas for the
pediatric population, the greatest risks are pulmonary and
airway complications. However, cardiac conditions
together with coagulopathy, anemia, pregnancy and
reactions to anesthesia may increase the risk in the pediatric
population and must also be given due consideration. In
account for the greatest fraction of operative and post –
operative risk and, therefore, necessitate evaluation during
surgery. 2,3 Patients at high risk usually fall into two
categories: . those at increased risk for cardiovascular
complications and those at increased risk for non –
cardiovascular complications as given in Appendix A.2
The pre – operative evaluation has several components: history
taking, physical examination and laboratory examination, and
patient education.
Medical History. The patient history is the most important
component of the pre – operative evaluation.4 History taking
is more difficult in the pediatric population than in adults, as
one must rely on the reports and accounts of parents and/or
guardians, together with other caregivers, pediatricians and
neonatologists2, 5. Nevertheless, accurate history must be
obtained which directs the physician as to what laboratory
examinations are needed. In the medical history, the indication
for the surgical procedure must be elicited as well as allergies
and intolerances to medications, anesthesia or other agents;
known medical problems and their current status; surgical
history; current medications; immunization history; family
history and a focused review of each of the following: cardiac,
pulmonary, functional and hemostatic (or hematologic) status
and the possibility of severe anemia.2, 4, 5

27
PPS Policy Statement
Physical Examination includes obtaining the patient’s
anthropometrics, such as height and weight. The patient’s
vital signs including the blood pressure, heart or pulse rate
and respiratory rate must also be obtained. For the pediatric
population, it is imperative that both pulse and respiratory
rates be taken for a full minute during sleep or during a
quiet moment. A complete and thorough examination of
the major body systems must be done, with emphasis on
the head and neck, cardiac, pulmonary, gastrointestinal and
extremities.2,5
Laboratory Examinations. Abnormal findings elicited from
the medical history and physical examination may necessitate
further evaluation and laboratory examination to optimize
surgery and patient care. Such abnormal findings include
the presence of asthma or frequent upper and/or lower
respiratory tract infections in children and chest pain or
elevated blood pressure in adults. The required laboratory
examinations for pre – operative clearance is contentious.
There are varying opinions as to what is necessary and what
is not. The Institute for Clinical Systems Improvement (ICSI)
states that most laboratory examinations including
hemoglobin, potassium, coagulation studies, chest X – rays
and electrocardiograms (ECG) are not necessary with routine
procedures unless a specific indication is present, and that
ECGs, regardless of age, are not indicated for those having
cataract surgery2. Specific indications for particular tests as
recommended by ICSI are given in Appendix B. On the other
hand, one author stated that routine hematocrit is of
importance in infants less than 6 months old who are
undergoing surgery due to an increased incidence of
unrecognized anemia which is a risk factor for perioperative
apnea and cardiac arrest6. In the Philippines, there are no
consensus nor guidelines on the laboratory examinations
needed in the pre – operative risk assessment. Most
physicians order laboratory examinations based on the
routine practices in their institutions. The working group for
this policy statement recommends the following laboratory
examinations to be done routinely when obtaining pre –
operative clearance in the pediatric population: complete
blood count with hematocrit, differential count and quantified
platelet count as well as a chest X – ray (PA-Lateral).
Patient education is essential to prepare the patients and their
parents or caregivers for the operation and to ensure the
compliance of the patient in the preoperative instructions.
Patient education must be procedure-specific and must give a
general orientation to the patients and their families of what
is to happen and the possible risks and complications during
surgery.2
Once the patient has been evaluated by a pediatrician, it is the
pediatrician’s prerogative whether to order additional
laboratory examinations or to refer the patient to a
28
Pre-Operative Evaluation in Pediatric Patients
corresponding specialist. Patients with existing problems or
co-morbidities should have the pediatrician and a specialist
on board and should be evaluated by both. At the end of the
pre – operative evaluation, the pediatrician should indicate in
the patient’s records the complete diagnosis and whether or
not there is any contraindication to surgery.
For patients undergoing high risk operations, further
adjunctive evaluation may be necessary aside from the basic
pre – operative risk assessment as above. Such high – risk
procedures include cardiac procedures, aortic and other major
vessel vascular procedures, peripheral arterial vascular
procedures, pancreatic resection, major spinal and orthopedic
surgery, intrathoracic, intraperitoneal, head and neck surgery
and prolonged surgical procedures associated with large fluid
shifts and or major blood loss.2,7
Adequate, appropriate, accurate and thorough pre – operative
evaluation and clearance in the pediatric population have
several advantages, including reduction of diagnostics
performed without clear indication, decreased delay and
cancellation of surgical procedures and most of all, decreased
operative and post – operative morbidity and mortality.2,4
RECOMMENDATIONS
Role of the Government
1. The government should facilitate the dissemination of
information to all health facilities.
Roles of the Attending Physician
1. The physician must be aware of the policy guideline
prepared by the Philippine Pediatric Society on the pre-
operative evaluation of the pediatric population.
2. The physician must be updated on the risks and
complications of the contemplated procedure.
3. The physician must inform the parents of the need for a
pre – operative evaluation.
4. The physician must be responsible in explaining to the
parents the various components of the evaluation process
as well as the risks of the contemplated procedure.
Role of the Pediatrician
1. The pediatrician must be aware and guided by the policy
guidelines set by the Philippine Pediatric Society.
Roles of Parents
1. The parents should inquire on the contemplated
procedure, risks and possible complications of the
operations that their child will be undergoing.
2. The parents should cooperate with the physicians in the
pre – operative evaluation of the patient and should give
truthful answers during the interview and history taking.
Pre-Operative Evaluation in Pediatric Patients PPS Policy Statement

Document prepared by the Committee on Policy

Statements
Chairperson: Carmencita D. Padilla, MD, MAHPS
Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma
Makalinao, MD
Members: Nerissa Dando, MD; Joselyn Eusebio, MD;
Edilberto Garcia, Jr., MD; Ramon Severino MD
Advisers: Joel Elises, MD; Salvacion Gatchalian, MD;
Genesis Rivera, MD; Jocelyn Yambao-Franco, MD
Research Associates: Maria Theresa H. Santos, MD; Gloria
Nenita V. Velasco, MD
ACKNOWLEDGEMENTS
The Committee on Policy Statements recognizes the
contribution of the following:
Philippine Society for Pediatric Cardiology
Child Neurology Society of the Philippines
Philippine Society for Pediatric Anesthesia
Philippine Society of Pediatric Surgeons

REFERENCES
EXPERT REVIEWERS
1. Kelly MM and Adkins L. “Ingredients for a successful
Philippine Society for Pediatric Cardiology pediatric preoperative care process – Clinical
Ma. Bernadette A. Azcueta, M.D. Innovations.” AORN Journal. May 2003.
2. Institute for Clinical Systems Improvement. “Preoperative
Child Neurology Society of the Philippines evaluation.” Bloomington (MN): Institute for Clinical
Marissa Lukban, M.D. Systems Improvement. July 2006.
3. Chopko, Michael. “Preoperative cardiac clearance for
Philippine Society for Pediatric Anesthesia Non – cardiac surgery.” Available at http://
Marichu Battad, M.D. www.diagnosisheart.com/showarticle.php?articleid=365.
Accessed on September 17, 2007.
Philippine Society of Pediatric Surgeons 4. Hawes, D. “Integrated Preoperative Patient Care.”
Delfin Cuajunco, M.D. 5. Ferrari LR. “Preoperative Evaluation of Pediatric Surgical
Patients with Multisystem Considerations.” Anesthesia
and Analgesia. Vol. 99. 2004. Pp. 1058 – 1069.
6. Hollinger, I. “Current Trends in Pediatric Anesthesia.”
The Mount Sinai Journal of Medicine.” Vol. 69, No. 1
and 2. January/March 2002. Pp. 51 – 54.
7. Karnath, BM. “Preoperative Cardiac Risk Assessment.”
American Family Physician. Vol. 66, No. 10. November
15, 2002. Pp. 1889 – 1896.

DISCLAIMER:
The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision
of quality health care to children. The recommendations contained in this publication do not dictate an exclusive
course of procedures to be followed but may be used as a springboard for the creation of additional policies.
Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and
advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences
in the specific approach. All information is based on the current state of knowledge. Changes may be made in this
publication at any time.

29
PPS Policy Statement Pre-Operative Evaluation in Pediatric Patients

APPENDIX A

Cardiovascular
• Unstable coronary syndromes
o Recent* myocardial infarction (MI)
o Unstable or severe angina

* Recent can mean less than 30 days if post myocardial infarction cardiac risk stratification is completed and patient
determined to be low-risk; 3 to 6 months if formal risk stratification not done.

• Decompensated congestive heart failure

• Significant arrhythmias
o High grade atrioventricular block
o Symptomatic ventricular arrhythmias in the presence of underlying heart disease
o Supraventricular arrhythmias with uncontrolled ventricular rate
• Severe valvular disease
• Severe hypertension (diastolic over 110, systolic over 180)
• Congenital heart abnormalities in pediatric patients

Non-Cardiovascular
• Pulmonary disease, severe or symptomatic (e.g., chronic obstructive pulmonary disease requiring oxygen, respiratory
distress at rest, asthma, cystic fibrosis, etc.)
• Poorly controlled symptomatic diabetes (causing symptoms with attendant risk of hypovolemia)
• Symptomatic anemia

APPENDIX B
Test Consider performing if:
ECG No ECG within last year in patients (regardless of age) with history of diabetes, hypertension,
chest pain, congestive heart failure, smoking, peripheral vascular disease, inability to exercise, or
morbid obesity. At time of preoperative evaluation, testing should occur in patients with any
intercurrent cardiovascular symptoms or with signs and symptoms of new or unstable cardiac
Coagulation Studies disease.
Patient has a known history of coagulation abnormalities or recent history suggesting coagulation
problems or on anticoagulants. Patient needs anticoagulation post-operatively (where a baseline
Hemoglobin may be needed).

Potassium Patient has a history of anemia or history suggesting recent blood loss or anemia.

Chest X-Ray Patient is taking digoxin or diuretics.

Patient has signs or symptoms suggesting new or unstable cardiopulmonary disease.

30
 PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association
In the Service of the Filipino Child

PPS Policy Statements Series 2009 Vol. 1 No. 7

Sports Clearance

Philippine Pediatric Society, Inc.

Philippine Society of Pediatric Cardiology

Children are encouraged to engage in sports and reap its multiple benefits. However, there
are instances when this involvement could lead to more harm than good. A sports clearance
achieves many goals and may be used to detect life-threatening health conditions, determine
readiness for sports participation and as a venue for counseling, among others. Though it has
limitations, a sports clearance by qualified medical personnel is nonetheless recommended
by the Philippine Pediatric Society, Inc. for all children who are about to engage in sports.

Keywords: sports clearance, preparticipation physical evaluation, athletic screening, sports

participation
URL: http://www.pps.org.ph/policy_statements/sports_clearance.pdf

BACKGROUND conducted by non-medical or medical personnel prior to

Participation in sports on a regular basis allows a child to
reap the multiple benefits of physical activity.1-4 The possible
physical benefits include improved motor skills, endurance,
cardiovascular fitness, muscular strength, lean body mass, and
peak bone mass.1,2,3,5,6 It also has social, psychological, and
behavioral benefits as well.2,4,5 It may serve as an adjunct
therapy for obesity, diabetes, and asthma.7-12 With all its
benefits, it is but natural that we encourage our children to
engage in sports. Sports participation is even supported by
the state as embodied in Article XIV Section 19 of the 1987
Philippine Constitution, “ … [the] State shall promote physical
education and encourage sports programs, league
competitions, and amateur sports, including training for
international competition, to foster self-discipline, teamwork,
and excellence for the development of a healthy and alert
citizenry.”13
Sports clearance, more commonly known as a
preparticipation physical evaluation or athletic screening, is
often asked of an individual who will indulge in sports
activities. It is a medical evaluation that includes a record of
the patient’s medical history (i.e. personal and family history
of cardiovascular diseases, history of neurologic and
musculoskeletal problems, medications and substance abuse
history) and a limited physical examination.14. It is usually
sports participation but may be done at interim periods for
athletes.4, 15 At present, there is no consensus document that
is in use as to when this should be done and who are
authorized to conduct the examination.
The following are the objectives of a preparticipation physical
evaluation:
1. To detect medical or musculoskeletal conditions that may
predispose the child to injury or illness during sports
activities;
2. To detect potentially life-threatening or disabling medical
or musculoskeletal conditions that may limit a child’s safe
participation in sports;
3. To determine the general health of the child;
4. To assess the fitness level of the child and his/her
appropriateness for a specific sport; and
5. To counsel and educate the child on health related issues,
e.g. the use of gateway drugs, unhealthy sexual practices,
and psychosocial issues.
A good sports clearance allows the physician to detect an
underlying medical problem that may aggravate or increase
the risk of injury with sports participation.16 There are medical
conditions, usually cardiac in origin, which require special
attention because of their associated potential risk for sudden

31
PPS Policy Statement
death. These conditions include hypertrophic cardiomyopathy,
coronary artery abnormalities, and increased cardiac mass.
Other less common causes include myocarditis, Marfan
syndrome, mitral valve prolapse, dysrhythmias, aortic stenosis,
Wolff-Parkinson-White syndrome, idiopathic long QT
syndrome, arrhythmogenic right ventricular dysplasia, cocaine
and anabolic steroid use, bulimia, anorexia nervosa,
bronchospasm, and heat-related illness. 18-20 Of these,
hypertrophic cardiomyopathy is the leading cause of sports-
related sudden death in the United States. In the United States
and United Kingdom, the incidence of sudden death has been
estimated to be 1 in 50,000 to 67,000, occurring mostly in
adolescent athletes.21
For the majority of chronic health conditions, however, current
evidence supports the participation of children and adolescents
in most athletic activities, but their physical condition and
progress should be monitored.17 Musculoskeletal conditions
may predispose the child to further injury16 if these are not
properly recognized. The physician should investigate any old
injuries and inquire into their rehabilitation.4,16,22 Possible
overuse injuries, e.g. tendinitis, apophysitis, stress fractures,
and injuries to epiphyseal growth centers may also be
investigated.23
The evaluation may also allow the physician to develop a
sound professional relationship with the child and his/her
parents. This will allow the following:
1. The child and parents to raise concerns, ask questions,
and discuss any issues that may affect the child (e.g.
nutrition, substance abuse, pregnancy prevention);
2. The physician to provide counseling that is relevant to
sports participation (e.g. risks of injuries, use of protective
equipment, risk of heat stress) and to his/her development
(e.g. readiness to join sport, sexual maturation,
psychosocial development); and
3. For continuing care of the child all throughout and even
after his/her sports participation.4,16,17,23-26
There are those, however, who question the usefulness of a
sports clearance, i.e. whether the clearance can significantly
save lives by preventing sudden death. 27 In a study done by
Epstein and Maron in the United States, “[it] was estimated
that 200,000 children and adolescents would have to be
screened to detect 1,000 athletes who are at risk for sudden
death and one person who would actually die.”18 On the other
hand, in an Italian study wherein the incidence of mortality
among athletes was observed over a period of two decades,
there was note of a declining incidence of sudden death that
paralleled the implementation of a preparticipation medical
clearance required for all athletes.28 The limitation of this
study was that only hypertrophic cardiomyopathy was
32
Sports Clearance
successfully identified; other cardiac causes of sudden death
were not.29
Furthermore, not all potentially lethal conditions can be
detected by a medical history and physical examination.
Although the history is recommended as the most practical
means of detecting a potentially lethal medical condition, its
specificity for detecting cardiovascular abnormalities is low.
In addition, asymptomatic patients with cardiovascular
problems but with a noncontributory family history may yield
unremarkable medical histories. Similarly, not all conditions
may be detected during the physical examination.15,18
There is yet no consensus document or protocol in clearing a
patient for sports participation, though it is being advocated by
many agencies. In the United States, there are those that are
comprehensive even by medical standards and those that are
inadequate.15 In the Philippines, no study has yet been done
and no recommendations have been made on athletic screening,
preparticipation physical evaluation or sports clearance.
The American Heart Association has published
recommendations regarding cardiovascular preparticipation
screening of competitive athletes for health professionals in
1996. For the cardiovascular history, the following have been
recommended for inclusion:
1. Prior occurrence of exertional chest pain/discomfort or
syncope/near-syncope as well as excessive, unexpected,
and unexplained shortness of breath or fatigue associated
with exercise;
2. Past detection of a heart murmur or increased systemic
blood pressure; and
3. Family history of premature death (sudden or otherwise),
or significant disability from cardiovascular disease in
close relative(s) younger than 50 years old or specific
knowledge of the occurrence of certain conditions (eg,
hypertrophic cardiomyopathy, dilated cardiomyopathy,
long QT syndrome, Marfan syndrome, or clinically
important arrhythmias…
The cardiovascular physical examination should emphasize
(but not be necessarily limited to):
1. Precordial auscultation in both the supine and standing
positions to identify, in particular, heart murmurs
consistent with dynamic left ventricular outflow
obstruction;
2. Assessment of the femoral artery pulses to exclude
coarctation of the aorta;
3. Recognition of the physical stigmata of Marfan syndrome;
and
4. Brachial blood pressure measurement in the sitting
position.15
Likewise, there is no worldwide consensus on whether or not
diagnostics, like electrocardiography or echocardiography, are
Sports Clearance
to be routinely included in the examination. In Europe, a Study
Group of the European Society of Cardiology in 2005
recommended the use of electrocardiography in combination
with medical history and physical examination in a sports
clearance. 28 In the United States, electrocardiography,
echocardiography, or exercise stress testing are not considered
to be cost-effective and have yet to be recommended as
screening measures by the American Heart Association.15.18
In 1997, a Preparticipation Physical Evaluation Task Force
composed of several medical societies in the United States
published a second edition of guidelines for physicians who
perform preparticipation physical evaluations.18 The need for
a screening protocol, however, is recognized and generally
advocated.15,28
Sports clearances are done in the Philippines; however,
majority may be the kind of medical clearance that is similar
to what is required for employment. Of the numerous amateur
and professional athletic groups, how many require sports
clearances for their athletes? For a child who is interested in
sports and has yet to participate, will he/she undergo such a
clearance? Who conducts these examinations in the country?
Are the medical clearances conducted adequate? Do we
subject all those who undergo a sports clearance to
electrocardiography and other diagnostics immediately? These
questions have yet to be answered.
RECOMMENDATIONS
Children and adolescents who may or may not be athletes are
referred to as children in the following recommendations.
Roles of Government
1. The government should mandate that all children should
undergo a sports clearance prior to sports participation.
2. The government should mandate that sports clearances
be conducted only by qualified medical personnel.
3. The government should mandate that all medical
personnel with an interest to clear children for sports
participation must undergo training or certification to do
so.
Roles of Hospital Administrators
1. Hospital administrators should certify that medical
personnel who conduct sports clearances be qualified to
clear children for sports participation.
2. Hospital administrators should establish training and
certification programs for medical personnel who are
interested in performing sports clearances on children.
Roles of Physicians
1. Physicians who clear children for sports participation
should undergo proper training and acquire certification
PPS Policy Statement
that would license them to perform a sports clearance.
2. Physicians must include in the medical history of a child
undergoing a sports clearance the following points: (1)
prior occurrence of exertional chest pain/discomfort or
syncope/near-syncope as well as excessive, unexpected,
and unexplained shortness of breath or fatigue associated
with exercise; (2) past detection of a heart murmur or
increased systemic blood pressure; and (3) family history
of premature death (sudden or otherwise), or significant
disability from cardiovascular disease in close relative(s)
younger than 50 years old or specific knowledge of the
occurrence of certain conditions (eg, hypertrophic
cardiomyopathy, dilated cardiomyopathy, long QT
syndrome, Marfan syndrome, or clinically important
arrhythmias).15
3. Physicians must include in the physical examination of a
child undergoing a sports clearance the following systems:
(1) precordial auscultation in both the supine and standing
positions to identify, in particular, heart murmurs
consistent with dynamic left ventricular outflow
obstruction; (2) assessment of the femoral artery pulses
to exclude coarctation of the aorta; (3) recognition of the
physical stigmata of Marfan syndrome; and (4) brachial
blood pressure measurement in the sitting position.15
4. If a physician detects an abnormality or raises suspicion
on history-taking or physical examination, he/she must
refer the child immediately to and coordinate with a
qualified specialist (e.g. sports medicine specialist,
orthopedic surgeon, cardiologist, physiatrist, etc.) for
further evaluation of the child.
5. A p h y s i c i a n w h o c l e a r s a c h i l d f o r s p o r t s
participation must coordinate with the child’s
primary physician to assure continuing care. If the
child is without a primary physician, the physician
who conducted the sports clearance must assume the
role of primary physician.
6. A physician who clears a child for sports participation
must endorse his/her patient to another qualified
physician if he/she will be unable to provide the child
continuing care during the entire sports participation
period.
Roles of Parents and Caregivers
1. Parents and caregivers should ensure that children
interested in sports participation, or are active in sports
(but have never had a sports clearance), be cleared by a
qualified physician.
2. Parents and caregivers should ensure that physicians who
conduct sports clearances have undergone the proper
training and have been certified.
3. If the physician raises suspicion after conducting a sports
clearance, the parents and caregivers should ensure that
the necessary work-up (e.g. consultation with a specialist,
diagnostic examinations) is done.
33
PPS Policy Statement
4. Regardless of the results of the sports clearance, the
parents and caregivers’ decision-making should be
directed by what would be in the child’s best interest,
i.e. possible non-participation in sports.
5. If the parents and caregivers decide to go against
medical advise of non-participation in sports, they and
the child must be made aware of the risks of sports
participation to the child’s physical health. The parents
and caregivers must also sign a waiver that they
acknowledge the risks and possible lethal consequences
of sports participation (if applicable) and are willing to
take those risks.
Document prepared by the Committee on Policy
Statements
Chairperson: Carmencita D. Padilla, MD, MAHPS
Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma
Makalinao, MD
Members: Nerissa Dando, MD; Joselyn Eusebio, MD;
Edilberto Garcia, Jr., MD; Ramon Severino MD
Advisers: Joel Elises, MD; Salvacion Gatchalian, MD;
Genesis Rivera, MD; Jocelyn Yambao-Franco, MD
Research Associates: Maria Theresa H. Santos, MD; Gloria
Nenita V. Velasco, MD
PANEL OF EXPERT REVIEWERS
Philippine Center for Sports Medicine
Raul C. Canlas, MD
Philippine Society for Pediatric Cardiology
Jonas del Rosario, MD
Pediatric Orthopaedic Society of the Philippines
Teresita L. Altre, MD, FPOA
PPS School Committee
Cynthia Cuayo-Juico, MD
Private School Health Officers Association
Dolores Sepacio, RN
ACKNOWLEDGEMENTS
The Committee on Policy Statements recognizes the
contribution of the following:
Philippine Center for Sports Medicine
Philippine Society for Pediatric Cardiology
Pediatric Orthopaedic Society of the Philippines
PPS School Committee
34
Sports Clearance
Private School Health Officers Association
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